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Handbook of Therapy 



OLIVER T. OSBORNE, M.D. 

Professor of Therapeutics, Yale University Medical School 

NEW HAVEN. CONN. 
AND 

MORRIS FISHBEIN, M.D. 

Assistant to the Editor, Journal American Medical Association 

CHICAGO 



SIXTH EDITION 
REVISED AND ENLARGED 



1920 



AMERICAN MEDICAL ASSOCIATION 
535 NORTH DEARBORN STREET. CHICAGO 



.On . 



Copyright 1920 

BY THE 

American Medical Association 



OCT -6 1920 
©CI.A576794 



PREFACE 



The sixth edition of this handbook is necessitated 
by material changes in our knowledge of the etiology 
and pathology of many diseases as well as in our 
knowledge of the actions of drugs. Many articles have 
been entirely rewritten, notably those on influenza and 
pneumonia. Several subjects allied to therapy have 
been omitted to make space for an enlarged discussion 
of some diseases and for the insertion of new articles. 
The objective has been constantly kept in mind of a 
small handbook that shall suggest an up-to-date treat- 
ment for the diseases considered. 

Oliver T. Osborne, M.D. 
Morris Fishbein, M.D. 
October, 1920. 



CONTENTS 



PAGE 

Preface to the Sixth Edition 5 

Prescription Writing 13 

Introduction 13 

Official Preparations and Useful Drugs 15 

Synonyms . 20 

Thermometric Equivalents 20 

Weights and Measures 20. 

Incompatibility ■ 24 

The Harrison Narcotic Law 25 

Prescribing Alcohol 26 

Latin 27 

Dosage 28 

Methods of Administering Drugs 31 

Classification of Drugs 33 

Treatment of Poisoning 39 

Class I. Irritants of the Gastro-Intestinal Canal 39 

Class II. Irritants of the Central Nervous System 42 

Class III. Depressants of the Nervous and Circulatory 

Systems 44 

Table of Special Symptoms and Special Treatment of 

Various Poisons 46 

Useful Drugs 50 

Some Therapeutic Principles 61 

Individual Tendencies 61 

The Family History 61 

Unscientific Prescribing 62 

Therapeutics More Than Medicine 62 

Pain as a Symptom 64 

Infectious Diseases 65 

Scarlet Fever 65 

Measles 77 

Whooping Cough 82 

Diphtheria 89 

Laryngeal Diphtheria 103 

Septic Sore Throat 104 

Rubella (German Measles) 105 



8 CONTENTS 

PAGE 

Chicken-Pox ; Varicella 106 

Mumps 107 

Epidemic Meningitis 109 

Acute Anterior Poliomyelitis 114 

Typhoid Fever 134 

Typhus Fever 145 

Influenza : Grip 147 

Pneumonia 155 

Rheumatism 172 

Chronic Arthritis 175 

Arthritis Deformans 178 

Erysipelas 179 

Botulism 180 

Tetanus 182 

Malaria ...... 186 

Tuberculosis 189 

Diseases of the Respiratory Tract 224 

Common Colds 224 

Acute Pharyngitis 231 

Coughs 232 

Acute Bronchitis 235 

Asthma 237 

Hay-Fever 247 

Diseases of the Gastro-Intestinal Tract 254 

Hygiene of the Mouth and Teeth 254 

Mouth Infections 255 

Pyorrhea Alveolaris 259 

Foul Breath 261 

Mouth-Washes and Gargles 264 

Care of the Teeth 267 

The Examination of Stomach Contents 268 

Examination of Feces 273 

Interpretation of Symptoms Referable to the Stomach 278 

Acute Dysentery 282 

Cholera 288 

Gastric and Duodenal Ulcer 290 

Hyperacidity 297 

Simple Catarrhal Jaundice 301 

Intestinal Stasis — Constipation 304 

Spastic Constipation 307 

Hookworm Disease 311 



CONTENTS 9 

PAGE 

Tapeworm 316 

Ascaris Lumbricoides : Round Worm 317 

Oxyuris Vermicularis : Pin Worms 318 

Diseases of the Kidney 320 

Pyelitis 320 

Renal Tuberculosis 322 

Albuminuria 323 

Acute Nephritis 325 

Chronic Nephritis 328 

Uremia 333 

Cystinuria 334 

Indicanuria 335 

Diseases of Metabolism 337 

Diabetes Mellitus 337 

Diabetes Insipidus 353 

Pellagra 354 

Gout 358 

Obesity 360 

Disturbances of the Heart 364 

Hypertension 364 

Acute Pericarditis 370 

Myocardial Disturbances 373 

Endocarditis 376 

Acute Heart Attack 389 

Broken Compensation 390 

Angina Pectoris 394 

Auricular Fibrillation 396 

Heart Block 400 

Disturbances of the Blood and Blood-Making Organs 402 

Anemia 402 

Pernicious Anemia 405 

Leukemia 409 

Hodgkin's Disease 411 

Purpura Hemorrhagica 413 

Hemophilia (Bleeders) 414 

Disturbances of Thyroid 420 

Hyperthyroidism 420 

Simple Struma of the Thyroid 423 

Hypothyroidism (Hyposecretion) 424 



1G CONTENTS 

PAGE 

Diseases of the Nervous System 434 

Chorea 434 

Epilepsy 436 

Headaches 441 

Sciatic Neuralgia and Sciatic Neuritis 446 

Brachial Neuritis 451 

Painful Feet 453 

Backache 454 

Neurasthenia 464 

Acute Intoxications 468 

Drug Addictions 468 

Lead-Poisoning 478 

Delirium Tremens 481 

Methyl, Wood, Alcohol Poisoning 487 

Nitrobenzene Poisoning 489 

Illuminating Gas Poisoning 490 

Heat Prostration and Sunstroke 492 

Asphyxia 497 

Trinitrotoluene Poisoning 500 

Mercuric Chlorid Poisoning 502 

Diseases of the Eye 507 

Ophthalmia Neonatorum 507 

Blepharitis 509 

Hordeolum (Stye) 511 

Iritis 511 

Burns of the Eye from Lime 514 

Floating Spots — Muscae Volitantes 514 

Diseases of the Ear 516 

Otitis Media 516 

Diseases of the Skin 520 

Pruritus : Itching .. 520 

Pruritus Ani 525 

Pruritus Vulvae 529 

Scabies 530 

Ringworm: Tinea Trichophytina 532 

Tinea Tonsurans 536 

Tinea Cruris 536 

Impetigo Contagiosa 538 

Psoriasis 540 

Boils and Carbuncles 453 

Alopecia : Baldness 547 



CONTENTS 11 

PAGE 

Urticaria 555 

Roentgen Dermatitis 558 

Chapped Hands 559 

Chilblain 560 

Frostbite 562 

Eczema 563 

Hyperkeratotic Eczema of Palms and Soles 568 

Sweating of the Feet and Axillae 569 

Burns 570 

Pediculosis 573 

Plant Poisoning 575 

Chloasma 577 

Boric Acid in Skin Diseases 578 

Picric Acid in Skin Diseases 581 

Syphilis and Diseases of the Genito-Urinary Tract 584 

Syphilis 584 

Acute Gonorrhea 596 

Prostatitis and Seminal Vesiculitis 605 

Chancroid 609 

Chronic Hypertrophy of the Prostate 610 

Obstetrics and Gynecology 618 

Toxemias of Pregnancy 618 

Vomiting of Pregnancy 620 

Eclampsia 624 

Puerperal Fever 628 

Postpartum Hemorrhage 635 

Dysmenorrhea 637 

Asphyxia Neonatorum 640 

Diseases of Infancy 646 

Infant Mortality and Feeding 646 

The Nervous Child 655 

Convulsions in Young Children 662 

Acidosis in Children 667 

Acute Diarrhea in Infants 671 

Food for Children from Two to Seven 673 

Incontinence of Urine in Children 677 

Physical Therapy 681 

The Local Application of Dry Hot Air 681 

Hydrotherapy 683 

Gruels and Starchy Drinks 687 

Albuminous Drinks 691 



12 CONTENTS 

PAGE 

Miscellaneous 693 

Anesthesia 693 

Disinfection 699 

Anaphylaxis — Allergy 703 

Vaccine Therapy 713 

Vaccination Against Smallpox 716 

Transfusion of Blood 719 



PRESCRIPTION WRITING 



INTRODUCTION 

Correct prescription writing is such a close corollary 
to good therapeutics that it seems pertinent to introduce 
it in this book. Although some of the material which 
appears in this and subsequent chapters may seem ele- 
mentary, it is hoped that the physician who reads it will 
pardon such detail in order that the subject may be 
presented entire. 

Therapeutics is the ultimate aim of the science and 
practice of medicine. It includes not only drug therapy, 
to which its definition is so often erroneously limited, 
but also everything that has to do with the treatment 
of disease, the management of the patient, his con- 
valescence, his permanent return to health, and the pro- 
tection of the well against disease. 

THE MANAGEMENT OF DISEASE 

The administration of drugs is only a small part of 
the successful management of disease. Successful 
management demands all the physiologic, chemical, 
anatomic, pathologic, bacteriologic and pharmacologic 
knowledge that can be obtained. It includes necessary 
hygienic changes, perhaps a change of climate, an 
arrangement of the food and drink, physical treat- 
ment if indicated, such mental treatment as is advisa- 
ble, such medicinal treatment as is needed, and neces- 
sary operative procedures. Altogether this is thera- 
peutics. The subject of therapeutics is, then, the 
broadest and the hardest one for the medical student 
to grasp, and it is safe to say that the young graduate 
in medicine, even after a hospital course, is less pre- 
pared in the bedside and office management of disease 
than in any other branch of his art. 

PSYCHOTHERAPY 

A proper understanding of the ability of the mind to 
overcome many nervous disorders, to prevent the mis- 
interpretation of, and the exaggeration of, slight physi- 
cal disturbances should be encouraged. Rational thera- 



14 THE PHARMACOPEIA 

peutics does not limit the physician to any one form of 
treatment ; it encourages him to use every means which 
may benefit his patient. 

PRESCRIBING PROPRIETARIES 

While simplicity in prescription-writing is advisable, 
the art of combining drugs or of rendering a drug less 
disagreeable should be studied and practiced until 
efficiency is secured. It is not justifiable for a physician 
to belittle his profession and forget rationality in his 
treatment of a patient by ordering secret or irrational 
proprietary mixtures. The physician who orders such 
preparations does not realize the positive harm he often 
does his patients, in some instances almost amounting 
to criminal negligence. No one deems it reputable, or 
scientific, or just to patients to prescribe preparations 
the ingredients of which he does not know. 

PHARMACOPEIA AND NATIONAL FORMULARY 

Few physicians know the range and compass of these 
books. No sane person would advocate using all of 
the heterogeneous mass of preparations included in 
them, but every physician can select the few formulas 
he may need that will be as elegant and pleasant 
methods of giving drugs as proprietary preparations 
and, moreover, will represent guaranteed doses of the 
various ingredients of the formulas selected. While 
the use of some of the ready made preparations is 
advised, it should be understood that it is much better 
to combine one's own prescription to fit the individual 
case. 

"useful drugs" 

This is a book describing the action and use of drugs 
that have positive therapeutic value; it is prepared 
under the direction and supervision of the Council on 
Pharmacy and Chemistry of the American Medical 
Association. It is intended to meet the demand for 
a less extensive materia medica and especially to serve 
as a basis for the teaching of materia medica and 
therapeutics and for examinations on these subjects by 
state licensing boards. It contains an especially 



PREPARATIONS . 15 

selected list of valuable preparations, picked from the 
vast number included in the Pharmacopeia, National 
Formulary and New and Nonofficial Remedies. 

NEW AND NONOFFICIAL REMEDIES 

The physician should be ever ready to make use of 
a valuable discovery, but never to further fraud. A 
new drug should be ordered straight or used only in our 
own combinations. New and Nonofficial Remedies is 
a book containing a list of new remedies, not ;in the 
Pharmacopeia, with a description of their preparation, 
their action and dosage. It is issued annually under the 
direction of the Council on Pharmacy and Chemistry. 
It enables the physiclian to know what proprietary 
preparations are reliable. 

OFFICIAL PREPARATIONS AND 
USEFUL DRUGS 

The principal preparations of the United States 
Pharmacopeia may be classified as follows : 

1. Solids mostly for internal use: 

A. Extracts (extracta). 

B. Pills (pilulse). 

C. Powders (pulveres). 

2. Liquids mostly for internal use: 

A. Waters (aquae). 

B. Elixirs (elixira). 

C. Emulsions (emulsa). 

D. Fluidextracts (fluidextracta). 

E. Infusions (infusa). 

F. Liquors (liquores). 

G. Mixtures (misturae). 
H. Spirits (spiritus). 

I. Syrups (syrupi). 

J. Tinctures (tincturse). 

3. Semisolids for external use: 

A. Cerates (cerata). 

B. Ointments (unguenta). 

4. Liquids for external use : 

A. Liniments (linimenta). 

B. Some waters (aquse). 

C. Some liquors (liquores). 

D. Some tinctures (tincturse). 



16 PREPARATIONS 

I. Solids Mostly for Internal Use 

A. Extracts are concentrated preparations of a 
drug, and are mostly moist and sticky. A few extracts 
are dry. They should be prescribed in pill or capsule. 
Extracts are usually four times the strength of the 
drug. 

The most important are : 

Extractum belladonna? foliorum Dose, 0.015 gm. or gr. X U 

Extractum cascarse sagradse Dose, 0.25 gm. or gr. iv 

Extractum fellis bovis Dose, 0.1 gm. or gr. iss 

Extractum opii Dose, 0.03 gm. or gr. V% 

B. Official pills are ready-made preparations, and 
consequently it should be remembered that they may 
have deteriorated or become more or less insoluble. 

The following pills have been much used. 

Blaud's pills (pilulse ferri carbonatis) contain 0.065 gm. 
(1 gr.) of iron. Should be made fresh when wanted. 
Dose, 2 pills. 

Pills of aloes (pilulse aloes) contain 0.13 gm. (2 gr.) of 

aloes. Dose, 2 pills. 
Compound rhubarb pills (pilulae rhei compositae) contain 

rhubarb 0.13 gm. (2 gr.) ; aloes 0.10 gm. (1% gr.) ; 

myrrh 0.06 gm. (1 gr.). Dose, 1 or 2 pills. 

C. Official powders are dry preparations of two or 
more drugs. It is better to order a powder by its 
official title, but below are the common names and the 
ingredients of the most used of these preparations : 

Dover's powder (pulvis ipecacuanhas et opii) contains 10 
per cent, each of ipecac and opium. Dose, 0.5 gm. (or 
gr. viii). 

Compound jalap powder (pulvis jalapas compositus) con- 
tains 35 per cent, of jalap and 65 per cent, of potassium 
bitartrate. Dose, 2 gm. (or gr. xxx). 

Compound licorice powder (pulvis glycyrrhizae compositus) 
contains 18 per cent, of senna ; 23 per cent, of glycyrrhiza ; 
8 per cent, of sulphur. Dose, 4 gm. (or 3i). 

Seidlitz powder (pulvis effervescens compositus) consists 
of two powders; one of Rochelle salt and bicarbonate of 
soda in blue paper, and the other of tartaric acid in 
white paper. Dose, the contents of one white and one 
blue paper dissolved in a glass of water. 



PREPARATIONS 17 

2. Liquids Mostly for Internal Use 

A. Waters are solutions of volatile substances in 
water; mostly weak preparations. (Exception, ammo- 
nia waters.) 

H. Spirits are solutions of volatile substances in 
alcohol; mostly strong preparations. (Exception, 
sweet spirits of niter.) 

F. Liquors are solutions of nonvolatile substances 
in water; mostly weak preparations. (Exceptions, the 
arsenic solutions and those for external use.) 

J. Tinctures are solutions of nonvolatile substances 
in alcohol; mostly strong preparations. (Exceptions 
are the aromatic and stomachic [bitter] drug tinc- 
tures.) 

A. Much used waters are : 

Aqua ammonise. 
Aqua camphorae. 
Aqua chloroformi. 
Aqua cinnamoni. 
Aqua menthse piperitae. 

H. Some of the commonly used spirits are : 

Spiritus ammonii aromaticus. 

Spiritus camphorae. 

Spiritus chloroformi. 

Spiritus glycerylis nitratis. 

Spiritus menthas piperitae (essence of peppermint). 

F. Some of the commonly used liquors are : 

Liquor calcis (lime water). 

Liquor cresolis compositus. 

Liquor formaldehydi. 

Liquor hydrogenii dioxidi. 

Liquor hypophysis. 

Liquor magnesii citratis. 

Liquor plumbi subacetatis. 

Liquor potassii arsenitis (Fowler's solution). 

Liquor potassii hydroxidi. 

Liquor sodae chlorinatae (Labarraque's solution). 

Liquor sodii hydroxidi. 



18 PREPARATIONS 

J. The most used tinctures are : 

Tinctura aconiti. 

Tinctura belladonnas foliorum. 

Tinctura benzoini composita. 

Tinctura capsici. 

Tinctura cardamomi. 

Tinctura cinchonae. 

Tinctura colchici seminis. 

Tinctura digitalis. 

Tinctura ferri chloridi. 

Tinctura gentianae composita. 

Tinctura hyoscyami. 

Tinctura iodi. 

Tinctura lobeliae. 

Tinctura myrrhae. 

Tinctura nucis vomicae. 

Tinctura opii, tinctura opii camphoratae and tinctura 

opii deodorati. 
Tinctura rhei aromatica. 
Tinctura scillae. 
Tinctura strophanthi. 
Tinctura zingiberis. 

B. Elixirs are sweetened liquid preparations con- 
taining alcohol. They are weak preparations, and the 
National Formulary contains a large number. 

C. Emulsions are liquid preparations representing a 
suspended oil or resin. 

D. Fluidextracts are liquids representing exact 
strengths of the drugs, i. e., 1 cubic centimeter (15 
minims) contains the medicinal properties of 1 gram 
(15 grains) of the drug. 

D. The most important fluidextracts are: 
Fluidextractum cascarae sagradae. 
Fluidextractum cascarae sagradae aromaticum. 
Fluidextractum ergotae. 

Fluidextractum glycerrhizae. 
Fluidextractum sennae. 

E. Infusions are weak watery preparations. One 
only is of value, viz., infusum digitalis. 

G. Mixtures are liquids containing more than one 
drug, often an insoluble one. Some much used in the 
past are: 

Brown mixture (mistura glycyrrhizae compositus). 
Chalk mixture (mistura cretae). 



PREPARATIONS 19 

The National Formulary contains a long list of mix- 
tures. 

I. Syrups are very sweet watery solutions of one or 
more drugs. These weak preparations are prescribed 
too frequently, as they readily cause disturbance of 
the stomach, and do not often modify a bad-tasting 
drug, but may even protract the taste. Sweet cough 
syrups are an abomination. Some much used syrups 
are: 

Syrupus. 

Syrupus ferri iodidi. 
Syrupus ipecacuanhae. 
Syrupus pruni virginianae. 
Syrupus rhei aromaticus. 
Syrupus scillse. 
Syrupus sennas. 
Syrupus tolutanus. 

j. Semisolids for External Use 

A. and B. The principal difference between cerates 
and ointments is their melting-points. The ointments 
contain more lard or petroleum fat and less wax than 
the cerates, hence they have a lower melting point 
than the latter. Cerates do not melt when applied to 
the skin. The following ointments are much used : 

Unguentum acidi borici. 
Unguentum belladonnas. 
Unguentum chrysarobini. 
Unguentum hydrargyri. 
Unguentum hydrargyri ammoniatum. 
Unguentum hydrargyri dilutum. 
Unguentum hydrargyri oxidi flavi. 
Unguentum picis liquidae. 
Unguentum sulphuris. 
Unguentum zinci oxidi. 

4. Liquids for External Use 

Some waters, some liquors, some tinctures and the 
liniments, as the name implies, are used externally 
only. Most of the liniments are stimulating to the 
skin, only two being sedative, viz., the belladonna lini- 
ment and the carron oil (linimentum calcis). 



20 WEIGHTS AND MEASURES 

SYNONYMS 
The following are frequently used synonyms : 

Aqua Fortis, Acidum nitricum, U. S. P. 

Aqua Regia, Acidum nitrohydrochloricum, U. S. P. 

Basham's Mixture, Liquor ferri et ammonii acetatis, U. S. P. 

Basilicon Ointment, Ceratum resinae, U. S. P. 

Black Draught, Infusion sennse compositum, U. S. P. 

Black Wash, Lotio nigra, N. F. 

Blaud's Pill, Pilula ferri carbonatis, U. S. P. 

Bleaching Powder, Calx chlorinata, U. S. P. 

Blue Mass, Massa hydrargyri, U. S. P. 

Blue Ointment, Unguentum hydrargyri dilutum, U. S. P. 

Blue Vitriol, Cupri sulphas, U. S. P. 

Brown Mixture, Mistura glycyrrhizae composita, U. S. P. 

Carron Oil, Linimentum calcis, U. S. P. 

Dobell's Solution, Liquor sodii boratis compositus, N. F. 

Donovan's Solution, Liquor arseni et hydrargyri iodidi, U. S. P. 

Dover's Powder, Pulvis ipecacuanha? et opii, U. S. P. 

Epsom Salts, Magnesii sulphas, U. S. P. 

Fowler's Solution, Liquor potassi arsenitis, U. S. P.. 

Glauber Salt, Sodii sulphas, U. S. P. 

Goulard's Extract, Liquor plumbi subacetatis, U. S. P. 

Gray Powder, Hydrargyrum cum creta, U. S. P. 

Gregory's Powder, Pulvis rhei compositus, U. S. P. 

Hive Syrup, Syrupus scillae compositus, U. S. P. 

Hoffmann's Drops, Spiritus aetheris, U. S. P. 

Huxham's Tincture, Tinctura cinchonas composita, U. S. P. 

Labarraque's Solution, Liquor sodas chlorinatae, U. S. P. 

Lugol's Solution, Liquor iodi compositus, U. S. P. 

Lunar Caustic, Argenti nitras fusus, U. S. P. 

Magendie's Solution, Liquor morphinae hypodermicus, N. F. 

Monsell's Solution, Liquor ferri subsulphatis, U. S. P. 

Sugar of Lead, Plumbi acetas, U. S. P. 

Vallet's Mass, Massa ferri carbonatis, U. S. P. 

Warburg's Pill, Pilula antiperiodica, N. F. 

Warburg's Tincture, Tinctura antiperiodica, N. F. 

Yellow Wash, Lotio flava, N. F. 

THERMOMETRIC EQUIVALENTS 

To convert degrees Centigrade to degrees Fahrenheit, 
multiply by 9, divide by 5, and add 32 to the quotient. To 
convert degrees Fahrenheit to degrees Centrigrade, substract 
32, multiply by 5 and divide by 9. A few commonly used 
equivalents are as follows : 

C. F. 

= + 32 Freezing point of water. 
37 = 98.6 Normal body temperature. 
40 = 104 

60 = 140 Sterilizing and Pasteurizing tempera- 
ture. 
100 = 212 Boiling point. 

WEIGHTS AND MEASURES 
It is not necessary to describe here the old system 
or to give its tables of weights and measures, as they 



I 



WEIGHTS AND MEASURES 21 

occur in every book on prescription-writing, but some 
tables of approximate equivalents to the metric sys- 
tem will be offered. Exact equivalent tables are a 
delusion and only, tend to befog and discredit the 
metric system. When it is remembered how the doses 
of drugs vary, it will be recognized how absurd it is 
to figure an equivalent to its finer determinations. 

It is not necessary to declare that the decimal 
(metric) system of prescription-writing is the better, 
because the fact is recognized by all and the only hin- 
drance to its use is the supposed difficulty of mastering 
it. Science of all countries has adopted it — even our 
own Pharmacopeia. If the novice in the use of the 
metric system in prescription-writing will remember 
that it is a decimal system like our monetary system, 
that everything on the left of the decimal point or line 
represents grams or cubic centimeters [dollars], that 
everything on the right of the decimal line represents 
centigrams, milligrams, or fractions of a cubic centi- 
meter [cents and mills], he will soon understand the 
system. 

In this country it is customary in writing prescrip- 
tions in the metric system to write for solids in terms 
of grams and fractions of grams, and for liquids in 
terms of cubic centimeters or fractions of cubic centi- 
meters or mils. We shall for the present continue to 
use the cubic centimeter for liquid measure though the 
new Pharmacopeia has adopted the mil as a unit. 
The same decimal line which should be ruled on the 
prescription blank answers for both solid and liquid 
metric measures, and precludes all possibility of care- 
less decimal mistakes, as : • 

gm. 
c.c. 



It is best to use in prescribing only two denomina- 
tions, grams and milligrams. Liquids, of course, are 
expressed as cubic centimeters. 



22 METRIC EQUIVALENTS 

TABLE OF THE APPROXIMATE EQUIVALENTS IN THE TWO SYSTEMS 

gm. 
c.c. 

1 grain (gr.i) = approximately 0|065 = 65 milligrams 

= 1 grain. 
1 minim (T7|,i) = approximately 0|065 = 6 %ooo of a cu- 
bic centimeter 
= 1 minim. 
15 grains (gr.xv) = approximately.. 1| =1 gram = 15 

grains. 
15 minims (nixv) = approximately. 1| = 1 cubic centi- 
meter = 15 
minims. 

1 dram (3i) = approximately 4| =4 grams = 1 

dram. 
1 fluidram (fl.3i) = approximately. 4| =4 cubic centi- 
meters = 1 
' fluidram. 

1 ounce (Si) = approximately 30| = 30 grams = 1 

ounce. 
1 fluidounce (fl.Si) = approximately. 30 1 = 30 cubic centi- 
meters = 1 
fluidounce. 

1 quart = approximately 1000 c.c, or 1 liter. 

1 pint = approximately 500 c.c. 

1 teaspoonful = approximately 5 c.c. 

As above declared, it is useless to translate the old 
system into exact equivalents of the new system. One 
must compute the doses in the new system; one must 
forget the size of stock bottles and order amounts of 
liquids in multiples of five, as 15 c.c, 25- c.c, 50 c.c, 
100 c.c, or 200 c.c ; one must remember that 5 c.c is 
a teaspoonful dose, i. e., an ordinary teaspoon holds 
5 c.c. and not 4 c.c or a liquid dram ; in other words, 
every prescriber in the old system has always given a 
larger dose than he intended when he computed the 
dose by fluidrams and then administered a teaspoonful ; 
one should remember that the drop, so much used in 
prescribing strong liquid preparations, is as correct in 
the new system as in the old. All of these suggestions 
must be followed out to us£ the metric system suc- 
:ess fully. 

It is always a good plan to use a stub prescription 
blank, and on the stub the individual doses may be 



METRIC EQUIVALENTS 



23 



written. This is another check on mistakes and also 
preserves for reference the exact dose given on the 
exact date, as : 



Stub (one dose) 



Strych. sulph. 1001 
Ferri reducti. 05 
Quin. sulph. . ( 10 

M. et F. cap. 

Sig. : t.i.d., p.c. 

Name. 

Age. 

Date. 



Prescription for 20 doses 



gm. 
I£ c.c. 

Strychninse sulphatis. . 102 

Ferri reducti 1 

Quininse sulphatis 2[ 

M. et F. capsulas 20. 
Sig.: A capsule 3 times a day, after 
meals. 



Old 
system 
gr.% 
gr.xv 
gr.xxx 



Or, 

Stub (one dose) 

Codein. sulph.. .01 
Ammon. chlor. .25 
Syr. acid. cit. . 1.25 
Aquae q. s..ad 5. 

M. 

Sig. : 5 c.c.q. 2 h. 
in H 2 0. 



Prescription for 20 doses 

gm. Old 

I£ . c.c. system 

(approximately) 
Codeinse sulphatis. . |20 gr.iv 

Ammonii chloridi.. - 5! 3iss 

Syrupi acidi citrici. 25 j fl.§i 

Aquae q. s ad 100 1 q. s. ad. fl.Biv 

M. 

Sig. : A teaspoonful, in water, every 
two hours. 
Shake. 



It is better to use the Arabic numerals instead of the 
Roman in the new system, as : 

Pilulas rhei compositas No. 20. 
Sig. : One pill after supper. 



Stub (single dose) 

Tr. digitalis. 

Sig. : 10 drops in 
H 2 b.i.d., p.c 



Prescription 

gm. Old 

B c.c. system 

Tincturae digitalis. .. 25 1 or fl.Si 

Sig. : Ten drops, in water, twice a day, 
after meals. 



Stub 


Prescription 




Ung. hg. ammon. 
Petrolati aa 10 

M. 

Sig. : Externally. 


gm. 

B c.c. 
Unguenti hydrargyri or 

ammoniati 101 

Petrolati 10 

M. 


Old 

system 

aa 3iiss 



24 INCOMPATIBILITY 

INCOMPATIBILITY 

This is prevented only by great care and simplicity. 
Too many drugs should not be prescribed. Too many 
solutions should not be combined. Too many drugs 
and too much medicine should not be given to one 
patient on any one or two days. Many drugs are 
cumulative and many of their physiologic activities 
are antagonistic. Drugs may be incompatible thera- 
peutically, chemically and pharmaceutical^. 

Therapeutic incompatibility occurs when drugs are com- 
bined which have antagonistic physiologic actions. 

Chemical incompatibility occurs when from the combination 
of two or more drugs a new and undesired chemical com- 
pound results. 

Pharmaceutic incompatibility occurs when drugs are com- 
bined which form, either immediately or later, cloudy, pre- 
cipitated or decomposed solutions. 

An educated physician should be ashamed to perpe- 
trate a therapeutic incompatibility either in a prescrip- 
tion or in a patient. It is not therapeutic incompati- 
bility, however, to modify a too decided action of a 
drug with one that corrects an undesired effect. This 
is a part of therapeutic science. 

Pharmaceutic incompatibility is so closely related 
to chemical incompatibility that many times both are 
governed by the same rule. Such incompatibility is 
difficult to avoid, and therefore it is advisable to adopt 
simplicity in prescription-writing; this is really a 
therapeutic gain. 

Below is given an alphabetic list of drugs which 
should generally be given alone, especially in solutions. 
The chemical reasons are appended : 

Acids, unless very dilute and in small amount, should be 
prescribed alone. They combine with bases to form salts, and 
are incompatible with oxids, alkalies, alkaline salts, hydrates 
and carbonates. They usually precipitate albumin. 

Alkalies and alkaline carbonates should rarely be prescribed 
in solution with other drugs. They form salts with acids and 
precipitate many metallic and alkaloidal salts. 

Alkaloidal salts should rarely be combined with other drugs 
in solutions. They are precipitated by alkalies, alkaline car- 
bonates, earthy carbonates, preparations containing tannic 
acid, and by iodids in solution. 



THE NARCOTIC LAW 25 

Arsenic (arseni trioxidum, arsenious acid) should gener- 
ally be prescribed in solutions alone. 

It is precipitated by salts of iron, magnesia, and solutions 
of lime. 

Bromids in solution should not be combined with alkaloids. 
They precipitate the salts of morphin, quinin, and strychnin 
from neutral solutions. 

Ferric and ferrous salts should generally be prescribed 
alone. They are incompatible with tannic acid and all drugs 
containing it; with alkaline carbonates, ammonia, and acacia. 

Iodids should generally be prescribed alone. 
They are incompatible with salts of alkaloids and metals 
and with mineral acids. 

Mercuric chlorid (corrosive sublimate) should generally be 
prescribed alone. It is incompatible with many drugs. 

Mercurous chlorid (calomel), though insoluble, had best 
not be prescribed in mixtures. In solutions containing 
chlorids it may be converted into the mercuric salt. 

Resins, including oleoresins, fluidextracts and tinctures 
containing resins, should not be prescribed in watery solu- 
tions, though they may be ordered in emulsion by suspending 
them with the mucilage of acacia or tragacanth. 

They are all precipitated by water. 

Silver nitrate solutions and solutions of all silver salts 
must be ordered alone, and kept in dark bottles. 

Strophanthus in the form of the tincture should not be 
prescribed in solutions containing water. 

Spirits (spiritus) should not be prescribed with watery 
preparations. They become cloudy on the addition of water. 

Tannic acid, and all drugs containing tannic acid, should 
not be prescribed with most drugs. They are incompatible 
with alkaloids, salts of iron, lead, silver and antimony. 

THE HARRISON NARCOTIC LAW 

This law affects the physician both as a prescriber 
and as a dispenser of drugs. It requires the pre- 
scribing physician to register with the collector of 
internal revenue of the district. In writing a prescrip- 
tion for narcotic or habit forming drugs, coming under 
this act, the physician must write thereon the name 
and address of the patient, and must have on the pre- 
scription" his office address and his registry number. 
He must date the prescription and sign his name in 
full. He need not keep either copies or records of 



26 PRESCRIBING ALCOHOL 

prescriptions ; this is done by the druggist. These pre- 
scriptions cannot be refilled. 

If the physician desires any of the specified drugs 
for his own use, he must make out an order for them 
on a blank form bearing his registry number. These 
blanks may be secured from the Internal Revenue 
Department. The physician cannot order drugs for 
his own use on a prescription blank. 

When he dispenses, the physician assumes the work 
of the druggist and is subject to the same rules. He 
must keep a record in a suitable book of all habit- 
forming drugs dispensed, the names and addresses of 
persons dispensed to and the dates. Such treatments 
as he may personally administer or cause to be admin- 
istered when away from his office need not be recorded. 

PRESCRIBING ALCOHOL 

Under the decision of the Commissioner of Internal 
Revenue, physicians may prescribe wines and liquors 
for internal use, or alcohol for external uses. Special 
regulations and forms for prescribing and for utilizing 
alcohol in medical practice have been issued. The 
physician may secure these from the commissioner in 
his district. In no case shall a physician prescribe alco- 
holic liquors unless the patient is under his constant 
personal supervision. 

The physician must see to it that the prescription 
indicates clearly the name and address of the patient, 
including street and apartment number, if any, the date 
when written, the condition or illness for which pre- 
scribed, and the name of the pharmacist to whom the 
prescription is to be presented for filling. 

The physician must also keep a record in which a 
separate page or pages is allotted each patient for whom 
alcoholic liquors are prescribed, and shall enter therein, 
under the patient's name and address, the date of each 
prescription, amount and kind of liquors dispensed by 
each prescription, and the name of the pharmacist fill- 
ing the prescription. 

Pharmacists are instructed to refuse to fill prescrip- 
tions if they have any reason to believe that physicians 
are dispensing for other than strictly legitimate medi- 
cinal uses, or that a patient is securing, through one 



LATIN 



27 



or more physicians, quantities in excess of the amount 
required for legitimate uses. 

A physician may secure alcohol for professional use 
only by securing a permit from the collector of internal 
revenue of his district. Permits may be obtained from 
the collector. Physicians who make application must 
do so on a special form and must make a statement 
that the liquor is for use in the course of their pro- 
fessional practice only, and that it is to be used either 
in the compounding of medicines or for use without 
change for non-beverage purposes only. 

The form of alcohol used in filling prescriptions — 
whether denatured or not — depends on whether the 
prescription is for internal or external use and on what 
kind of alcohol the prescription specifies. Nonbeverage 
alcohol, medicated or denatured so as to be unfit for 
beverage purposes, may be used for filling prescriptions 
if so indicated. 

LATIN 

As Latin is no longer required for matriculation by 
many medical schools it seems unwise to attempt to out- 
line the correct use of Latin in prescriptions in a book 
of this character. Therefore Latin rules are omitted 
from this edition of the Handbook. Prescriptions are 
well written in English with the United States Pharma- 
copeia Latin names or with the official abbreviations. 
However, the Latin abbreviations are so much used that 
a few are listed here with a statement of their 
meanings. 

Abbreviations 



reviation 


Latin 


Translation 


aa 


ana (Greek) 


of each 


ad 


ad 


up to 


cap. 


capsula, — ae. 


a capsule 


co. or comp. 


compositus-a-um 


compound 


div. 


divide 


divide 


ext. 


extractum, — i 


an extract 


fac 


fac 


make 


flext. 


fluidextractum, — i, 


a fluid extract 


hq. 


gutta, — ae 


drop or drops 


liquor, — is. 


a solution 


m. 


misce 


mix 


mist. 


mistura, — ae 


a mixture 


pil. 


pilula, — ae 


a pill 


pulv. 


pulvis, — eris 


a powder 


q. s. 


quantum sufficit 


a sufficient quantity 


ss. 


semis, semissis 


a half 


sig. 


signa 


write 


sol. 


solutio, — onis 


a solution 


spts. 


spiritus 


a spirit 


t. i. d. 


ter in die 


three times a day 


tr. 


tinctura, — ae 


a tincture 



28 DOSAGES 

DOSAGE 

The dose of a drug should be based on the age, 
weight and individuality of the patient, and the neces- 
sity for a strong action of the drug. 

The frequency of the dose is determined by the 
results obtained, by the length of time it takes the drug 
to be eliminated or cease its action, and the possibility 
of its causing a cumulative effect. 

While age is an all-important element in the deter- 
mination of the dose, the weight, unless in the obese, 
is the most important element, except in the case of 
narcotics given to children. Children have more cen- 
tral nervous system as compared to their weight than 
adults, and therefore are more profoundly affected by 
drugs which act on the brain than are adults. In 
other words, a given dose of a narcotic, especially of 
the opium series, for an adult must be more reduced 
in size for a young child than any table of reduction 
computed by age or weight would determine. 

The best simple rule of dosage by age is the fol- 
lowing : 

At 20 years, the adult dose. 
At 10 years, X A the age, V2 the dose. 
At 5 years, % the age, X A the dose. 
At 2% years, Vs the age, Vs the dose. 
At 1 year, H2 the dose. 

Children whose ages are between the ones here 
specified may readily be prescribed doses a little more 
or less than the dose determined by the age nearest 
theirs in the table. 

The relation of size and weight to the dose is all- 
important. A large child of 2 years should certainly 
receive a larger dose than a weakly, small child of the 
same age. Also a small adult of 20 should receive less 
than a large muscular individual of the same age. The 
blood of an adult represents about one-thirteenth of 
his total weight. This is not true of children or of the 
obese. Hence the dose of an obese individual may be 
even less than if his weight were normal. 

The following are the average weights for normal 
adult males. It should be remembered that females 
up to the age of 45 or 50 generally weigh less than 



DOSAGES 29 

males ; also that a range of from 25 to 30 pounds above 
or below the average weight, the patient's general con- 
dition being good, is not necessarily considered a 
weight too high or too low for acceptance as an insur- 
ance risk. Above or below this range of 25 to 30 
pounds from the average is generally considered over- 
weight or under-weight, and the acceptance of such 
an individual for insurance becomes questionable. 

TABLE OF AVERAGE WEIGHT TO HEIGHT AT DIFFERENT 

AGES 



hi In. 


15-24 


25-29 


30-34 


X 

35-39 


car 

40-44 


45-49 


50-54 


55-60 


5-0 


120 


125 


128 


131 


133 


134 


134 


134 


5-1 


122 


126 


129 


131 


134 


136 


136 


136 


5-2 


124 


128 


131 


133 


136 


138 


138 


138 


5-3 


127 


131 


134 


136 


139 


141 


141 


141 


5-4 


131 


135 


138 


140 


143 


144 


145 


145 


5-5 


134 


138 


141 


143 


146 


147 


149 


149 


5-6 . 


138 


142 


145 


147 


150 


151 


153 


153 


5-7 


142 


147 


150 


152 


155 


156 


158 


158 


5-8 


146 


151 


154 


157 


160 


161 


163 


163 


5-9 


150 


155 


159 


162 


165 


166 


167 


168 


5-10 


154 


159 


164 


167 


170 


171 


172 


173 


5-11 


159 


164 


169 


173 


175 


177 


177 


178 


6-0 


165 


170 


175 


179 


180 


183 


182 


183 


6-1 


170 


177 


181 


185 


186 


189 


188 


189 


6-2 


176 


184 


188 


192 


194 


196 


194 


194 


6-3 


181 


190 


195 


200 


203 


204 


201 


198 



In determining the dose it is most important to con- 
sider whether or not the patient has any exceptional 
susceptibility to the given drug. When an idiosyncrasy 
or abnormal susceptibility to a certain, drug or to 
drugs of a certain class is known, the drugs causing 
it should, if possible, not be administered. Hyper- 
sensitization, termed anaphylaxis, is a cause of idiosyn- 
crasy to some drugs. 

Sometimes such undesired action of a drug occurs 
with the first dose only, notably in the case of quinin, 
and a tolerance to the drug is, after this first dose, 
temporarily acquired. 

A patient may, on the other hand, be abnormally 
tolerant to a given drug, so that unusually large doses 
are necessary to cause an effect. 

Still other very important modifications of the dose 
are caused by disease, by the condition of the patient's 
digestive and absorptive system, and by the con- 
dition of his eliminative organs. The disease pres- 



30 FREQUENCY OF DOSES 

ent may create a tolerance or an increased suscepti- 
bility to a drug. Slow absorptive powers may render 
the action of the drug almost impossible or allow 
accumulation of dangerous amounts of the drug 
(under which conditions the drug should be given 
hypodermically, if it is needed). Slow or retarded 
elimination due to defective eliminative organs will 
allow accumulative action of many drugs. 

The drugs which are most frequently found unex- 
pectedly to cause undesirable or even serious symptoms 
in susceptible individuals are quinin, salicylates, atro- 
pin-containing drugs, iodin-containing drugs, and 
opium and its alkaloids. 

The diseased conditions that most modify (lessen) 
the dose of a drug are nephritis and cirrhosis of the 
liver. 

A condition of shock precludes immediate absorp- 
tion from the stomach, hence such a condition must 
be combated, if by drugs, hypodermatically. 

Frequency of the Dose 

It should be carefully learned how long, ordinarily, 
it takes a given dose of a drug to act, and how long 
before it is mostly eliminated. This determines the 
frequency of the dose. Also some drugs are elimi- 
nated so slowly that they tend to accumulate in the 
system or are deposited in the various organs so that 
medication may occur days and even weeks after the 
cessation of the administration of the drug. 

A few of the rapidly acting drugs are : 

Alcohol Iodids 

Ammonia Salicylates 

Camphor Strophanthin 

Caffein Strychnin 
Chloral 

These act in a few minutes to an hour or so, hence 
the intervals at which they may be given range from 
every hour to every three hours, or three times a day, 
according to the drug. 



ADMINISTERING DRUGS 31 

A few of the slowly acting drugs are : 

Arsenic Quinin 

Atropin Synthetic antipyretics 

Bromids Synthetic hypnotics 

Digitalis Thyroid 

Mercury 

These act in from several hours to twenty, hence 
should be given only once or twice a day, according to 
the drug. 

A few of the drugs that tend to accumulate in the 
system are: 

Arsenic Digitalis 

Atropin Mercury 

Bromids Strychnin 

Many drugs cause eruption on the skin either due 
to irritation of the stomach and duodenum or to their 
being more or less excreted by the skin and irritating 
the glands during such excretion, or they may cause 
flushing of the skin. 

Examples of drugs causing the first kind of irrita- 
tion are: copaiba, chloral, opium, quinin, salicylates, 
synthetic compounds, volatile oils ; drugs of the second 
type are arsenic, bromids and iodids; those of the 
third type are antitoxin, atropin and thyroid. 

It should always be remembered that some drugs 
are excreted into the milk; hence if the mother is 
nursing her baby, some drugs should be avoided, and 
some given only infrequently; or, on the other hand, 
the baby may be medicated through the mother. 

Generally speaking, most narcotics (opium, bromids, 
etc.), most metals and endocrine gland extracts 
(arsenic, mercury, iodids, thyroid), most cathartics and 
quinin are excreted in the milk. 

METHODS OF ADMINISTERING DRUGS 

Drugs and serums are more than occasionally admin- 
istered intravenously. As the technic requires skill 
and most perfect asepsis, this method should not fre- 
quently be resorted to. Moreover, when a drug or 
serum is injected intramuscularly, the rate of absorp- 
tion and activity are almost as rapid as when it is 
given intravenously, and the danger of accidents is 
much less. 



32 USE OF CAPSULES 

The hypodermatic or subcutaneous method is of 
very great value in all emergencies, but should not be 
used too frequently. Of course, the most frequent 
need for such medication is caused by pain, which must 
be combated by morphin or its equivalent. The 
danger of acquiring a habit is greater when the drug 
is used hypodermatically than when it is given in any 
other way. 

The usual method of giving a drug is by the mouth, 
either in liquid, powder, pill, cachet, capsule or tablet. 
A drug will act more quickly if given in liquid 
solution on an empty stomach. If it is disagreea- 
ble, however, it should be given in capsule if the 
character and dose of the drug will allow.' If a drug 
is irritant, it should not be given on an empty stomach. 
A disagreeable liquid drug should not be combined 
with a syrup, which does nothing but prolong the taste 
and upset the stomach, but should be given in plain 
water to be followed by any kind of taste the patient 
prefers, such as orange, lemon, or by a peppermint or 
wintergreen candy, for example. Or the liquid may be 
given in a sour mixture, as lemonade or syrup of citric 
acid and water, or it may be given in a mineral or car- 
bonated water. A powder may be given in milk or in 
an effervescing water. 

Capsules are the nicest means of giving drugs dis- 
agreeable in taste and small in dose. The contents of 
a capsule should be dry for rapid solution, the princi- 
pal advantage of a capsule over a pill. If rapid action 
is desired, or if it is feared that the capsule, slowly dis- 
solving on a small part of the mucous membrane of the 
stomach, will irritate the membrane, the capsule may 
be uncapped at the moment of swallowing, and the 
result is the same in the stomach as though the drug 
had been taken as a powder. Alcohol in any form in 
the stomach will retard the solution of a gelatin capsule. 
Pills are not so much used as before the capsule became 
so popular. The solution and absorption of a pill must 
be slow, unless it contains some particles 'of a substance 
that swells with water, as starch. Sugar, chocolate, 
or gelatin-coated pills and tablets make the solution 
still slower, though in the case of drugs to act on 'the 
intestine this may be of advantage. 



CLASSIFICATION OF DRUGS 33 

The much-used tablet, compressed or triturate, 
doubtless renders much medication valueless, and per- 
haps, fortunately, harmless. The speed of solution of 
most tablets on the market is problematic; hence if 
the action of a tablet is immediately desired it should 
be predissolved, or at least crushed by the teeth 
before swallowing. All antipyretic coal-tar tablets 
should be crushed before swallowing and then a good 
drink of water taken with them. It should not be for- 
gotten that anything that may bite or irritate the mem- 
brane of the mouth will do the same to the mucous 
membrane of the stomach. Hence bromid tablets 
should never be taken undissolved. Potassium chlo- 
rate tablets dissolved in the mouth or swallowed are 
dangerous. Potassium chlorate solutions for the 
mouth and throat are valuable, but there is no justifi- 
cation for ever taking potassium chlorate into the stom- 
ach or into the system. 

A very soluble tablet dissolved and absorbed from 
the mouth will give almost as rapid action as when 
given hypodermatically. 

The rectum absorbs drugs given by means of sup- 
positories or injections nearly and sometimes quite 
as rapidly as does the stomach. Sedatives and some 
laxatives only are administered by suppositories for 
systemic effect. 

A few drugs are given endermically, but except in 
the case of mercury the method is uncertain. 

Mucous membranes may be treated by douching, 
injection, insufflation, and those of the air passages by 
inhalation. Some drugs are absorbed by all of these 
methods, and if poisonous drugs are used, the "possi- 
bility of too great an absorption must always be kept 
in mind. 

CLASSIFICATION OF DRUGS 

While dictionaries and encyclopediaes must be 
arranged alphabetically for ready reference, alpha- 
betic arrangement of drugs for the practicing physician 
is very unsatisfactory. For a practicing physician, 
classification based on chemical constituency, pharma- 



34 CLASSIFICATION OF DRUGS 

cologic peculiarities, or toxic action is absolutely of no 
value. A drug may have a chemical, physiologic or 
toxic activity that is of no value from a therapeutic 
standpoint. The classification always of value and 
always necessary for the practicing physician is one 
based on therapeutic uses. 

The following classification selects certain drug for 
certain therapeutic indications. While this enumera- 
tion of drugs does not comprise all that are of value, 
it does comprise the best, and any drug that aspires to 
a place in such a classification, must show positive 
physiologic activity and therapeutic success to prove 
that it should be classed among these, the best drugs. 
Under each heading the drugs are named alphabetically 
and not in the order of their value. 

I. Drugs Applied for Their Local Action on the Skin, 
Wounds or Visible Mucous Membranes. 

Corrosives or Caustics. — Acetic acid, nitric acid, alum, sil- 
ver nitrate, phenol, potassium hydroxid, sodium car- 
bonate and sodium hydroxid, zinc chlorid. 

Disinfectants and Antiseptics. — Benzoic, boric and salicylic 
acids, silver nitrate, chlorid of lime, camphor, cresol, 
eucalyptus, formaldehyde, mercuric chlorid, mercuric 
iodid, hydrogen peroxid, iodoform, phenol, tar, potas- 
sium permanganate, sulphur thymol and zinc chlorid. 

Astringents. — Tannic - acid, alcohol, alum, liquor alumni 
subacetatis, bismuth subcarbonate, subgallate and 
subnitrate, copper sulphate, iron chlorid and sulphate, 
lead and zinc acetates, zinc oxid and sulphate. 

Styptics. — Soluble astringents, iron chlorid and alum. 

To Contract Vessels. — Epinephrin. 

Emollients: Powders.— Starch, bismuth subcarbonate and 
subnitrate, magnesium carbonate, talcum, zinc oxid. 

Protectives. — Lard, wool fat, white wax, collodion, fixed 
oils and petrolatum. 

Local Anodynes and Analgesics for Pain and Itchings. — 
Ammonia water, atropin, chloroform, cocain, phenol, 
and sodium bicarbonate. 

Local Anesthetics. — Ether, ethyl chlorid, cocain, menthol, 
procain and quinin and urea hydrochlorid. 



CLASSIFICATION OF DRUGS 35 

II. Drugs Used for Affections of the Alimentary Tract. 
Mouth and Throat. 

Demulcent. — Acacia, glycerin and potassium chlorate. 
To Lessen Salivation. — Atropin. 

Stomach. 
Digestives. — Hydrochloric acid and pepsin. 
Emetics. — Apomorphin hydrochlorid, emetin hydrochlorid, 

ipecac, mustard, sodium chlorid, zinc sulphate. 
To Lessen Irritation and Vomiting. — Bismuth subcar- 

bonate and subnitrate, chloral, choloroform, codein, 

lime water, menthol, morphin and opium. 
To Lessen Acidity. — Calcium and magnesium carbonates, 

lime water, magnesium oxid, sodium bicarbonate. 

To Increase Secretion, Bitters. — Quinine, gentian, nux 
vomica, strychnin. 

Carminatives. — Alcohol, camphor, capsicum, cardamom, 
cloves, volatile oils, ginger. 

Intestine. 

To Promote Digestion. — Pancreatic extract (?). 

To Promote Evacuation. — 

Vegetable Purgatives. — Aloes, aloin, colocynth, elaterin, 
jalap, podophyllum, cascara, rhubarb, castor oil, 
senna, croton oil. 

Saline Purgatives. — Magnesium carbonate, sulphate, 
oxid and citrate, potassium bitartrate, potassium and 
sodium tartrate, sodium phosphate and sodium sul- 
phate. 

Mercurial Purgatives. — Calomel, mercury with chalk. 

Miscellaneous. — Fel bovis, glycerin, sulphur, petrolatum 
and phenolphthalein. 

To Lessen Movement and Reflex Spasm. — Tannic acid, 
atropin, belladonna, bismuth subcarbonate, subgallate 
and subnitrate, lime water, morphin and opium. 

To Destroy Parasites, Anthelmintics. — Aspidium, chloro- 
form, calomel, pelletierin, salol, santonin, turpentine, 
thymol. 

III. Drugs Used for Their Effects on the Circulation. 
Heart. 

To Strengthen Contraction. — Digitalis, strophantus. 
To Accelerate Pulse. — Atropin, caffein, camphor. 
To Slow Pulse. — Aconite, digitaKs, strophantus. 



36 CLASSIFICATION OF DRUGS 

Vessels. 

To Contract Vessels and Raise Blood Pressure. — Epi- 
nephrin, ergot, hypophysis, atropin, caffein. 

To Relax Vessels and Lower Blood Pressure. — Amyl 
nitrite, nitroglycerin, sodium nitrite. 

To Remove Fluid. — Diuretics, diaphoretics, vegetable and 
saline purgatives. Also digitalis, calomel, squill, 
strophanthus. 

IV. Drugs Used for Their Effects on the Genito- Urinary 

System. 

To Increase the Flow of Urine, Diuretics. — Caffein, digitalis, 
calomel, potassium salts, squills, spartein sulphate, 
strophanthus, theobromin. 

To Render the Urine Less Acid. — Potassium acetate, bicar- 
bonate and citrate, sodium carbonate and bicarbonate. 

To Render the Urine Aseptic. — Benzoic and salicylic acids, 
acetylsalicylic acid, hexamethylenamin, salol, sandal- 
wood oil, sodium benzoate, sodium salicylate. 

To Promote Menstruation, Emmenagogues. — Vegetable pur- 
gatives, corpus luteum. 

V. Drugs Used for Their Effects on the Respiratory 

System. 

To Stimulate the Respiratory Center. — Atropin, caffein, 
camphor, strychnin. 

To Reduce the Irritability of the Center in Cough. — Chloro- 
form, codein, heroin, morphin, opium. 

To Increase and Liquefy the Bronchial Secretion. — Ammo- 
nium carbonate, apomorphin, ipecac, potassium iodid, 
squill, sodium iodid. 

To Lessen the Secretion of the Bronchi (f). — Benzoin, 
turpentine, atropin. 

To Relax Bronchial Spasm in Asthma. — Amyl nitrite, atro- 
pin, belladonna, nitroglycerin, potassium iodid, sodium 
iodid, sodium nitrite, chloral, morphin. 

VI. Drugs Used for Their Effects on the Central 

Nervous System. 

Stimulants. — (a) (the spinal cord) strychnin, (b) (the 
brain and medulla) atropin and caffein. 

Depressants. — (a) (to paralyze sensation) ether, ethyl 
chlorid, chloroform; (b) (to induce sleep and rest) 
alcohol, chloral, codein, morphin, opium, paraldehyde, 
scopolamin, sulphonal, barbital; (c) (to relieve pain) 



CLASSIFICATION OF DRUGS 37 

acetanilid, phenacetin, salicylic acid, alcohol, anti- 
pyrin, aspirin, chloral, codein, morphin, sodium 
salicylate. 

VII. Drugs Used to Reduce Fever Temperature. 

Actanilid, phenacetin, salicylic acid, aconite, antipyrin, 
aspirin, quinin, sodium salicylate. 

VIII. Drugs Used for Their Effects on the Liver. 
To Increase Bile. — Salicylic acid, fel bovis. 

IX. Drugs Used for Their Effects on the Blood. 

To Increase the Hemoglobin. — Arsenic and iron salts and 
combinations. 

To Render the Blood Alkaline. — Potassium acetate, bicar- 
bonate and citrate, sodium bicarbonate and carbonate 

To Increase the Coagulability (f). — Calcium salts, horse 
or human blood serum. 

X. Drugs Used for Specified Diseases. 
Malaria. — Arsenic, quinin. 

Syphilis. — Mercury, iodids, arsenic, arsphenamin. 

Rheumatic Fever. — Salicylates. 

Diphtheria. — Serum antidiphthericum. 

Tetanus. — Serum antitetanicum. 

Trypansomiasis. — Antimony and potassium tartrate, sodium 

arsanilate. > 
Gout. — Acidum phenylcinchonicum, colchici semen. 

XI. Drugs Used for Their Effects on the Skin. 

Irritants. — Alcohol, ammonia, camphor, cantharides, capsi- 
cum, menthol, mustard, turpentine, croton oil. 

Disinfectants or Irritants Used Chiefly in the Form of 
Ointments in Parasitic Skin Diseases. — Balsam of 
Peru, benzoin, camphor, chrysarobin, mercury, ich- 
thyol, iodin, tar, resorcin, sulphur, thymol. 

To Increase Sweat. — Camphor, ipecac, opium, pilocarpin. 
To Lessen Sweat. — Atropin, belladonna. 

XII. Drugs Used Locally for Their Effects on the Eye. 

To Dilate the Pupil and Relax Accommodation. — Atropin 

cocain, homatropin, scopolamin. 
To Contract the Pupil and the Ciliary Muscle. — Physostig- 

min salicylate, pilocarpin hydrochlorate. 



38 CLASSIFICATION OF DRUGS 

OTHER PROPERTIES OF WELL KNOWN DRUGS 

The following classification is taken from "Introduction to 
Materia Medica and Pharmacology" by Oliver T. Osborne. 

Drugs and Preparations Which May Cause an Eruption on, 
or Itching of, the Skin. — Antitoxin, arsenic, belladonna, 
bromids, chloral, copaiba, iodid, opium, quinin, salicylic 
acid, synthetic compounds, volatile oils and drugs con- 
taining them. 

Drugs Which May Change the Color of the Urine: 
Drugs that increase its amount cause it to be lighter. 
Drugs that irritate the kidneys cause it to be darker. 
Methylene blue causes it to be green, if acid. 
Phenol may cause it to be brown. 

Santonin causes it to be yellow, if acid; purple, if alkaline. 
Senna may cause it to be red if alkaline; yellow, if acid 
Sulphonal may cause it to be very dark. 

Drugs Which Color the Feces: 
Bismuth salts color them black or dark gray. 
Colchicum colors them greenish. 
Iron colors them black. 
Mercury colors them green. 
Purgatives cause them to be darker. 

Drugs Which Are Excreted with the Milk. — Arsenic, bromids, 
hexamethylenamin, iodids, lead, mercury, opium, quinin, 
sulphur, vegetable cathartics, volatile oils. 



TREATMENT OF POISONING 



As the symptoms and treatment of poisoning are 
many times so similar, it seems best to divide poisons 
into classes, and then to describe the treatment of each 
class, rather than to multiply individual descriptions. 

The following classification is of types of drugs. 
The individual drugs with references to the class to 
which they belong, and therefore to the treatment 
advisable, will be found in a table on another page. 

Class 1. — Irritants of the Gastro-Intestinal Canal. 
Acids. 
Alkalies. 
Irritant metallic salts. 

Class 2. — Irritants of the Central Nervous System. 
Atropin-containing drugs. 
Caffein-containing drugs. 
Cocain. 

Scopolamin (hyoscin). 
Strychnin. 
Volatile oils. 

Class 3. — Depressants of the Nervous and Circulatory 
Systems. 
All cardiac drugs in large doses. 
Coal-tar products. 
Cyanids. 
Hypnotics. 
Narcotic drugs. 
Nicotin. 
Most phenol-containing drugs. 

CLASS I. IRRITANTS OF THE GASTRO-INTESTINAL 

CANAL 

Most irritants in weak dilutions are astringent, while 
most astringents in strong solutions are irritant. The 
action of astringents and irritants on mucous mem- 
branes is, therefore, largely one of degree. Some 
astringents act chemically to form albuminates with 
the protein substance found on moist mucous mem- 
branes, thus coating and preventing the further irri- 
tation of the membrane. At the same time the blood- 
vessels of the membrane are contracted, the membrane 



40 TREATMENT OF POISONING 

is dried, and the secretion diminished. This is typical 
metallic astringent action. If this albuminate is insol- 
uble or very slowly soluble in the media surrounding 
it the action just described is the only action due to 
the astringent, viz., there may be more or less pro- 
nounced irritation at first, but the after-effect is seda- 
tive. If, however, this albuminate tends to dissolve 
at its junction with the mucous membrane, the action 
of astringency is then continued and may become so 
irritating as to cause severe inflammation or with some 
metallic salts or acids cause ulceration and corrosion. 
Such drugs or preparations are called "gastrointes- 
tinal irritants," and in poisonous doses will all pro- 
duce the same immediate symptoms. Later individual 
symptoms or conditions develop due to the character 
of the substance absorbed, to its chemical nature and 
to the amount of local corrosion that it can cause. 

Different metals have different powers of astrin- 
gency and irritant action; also different salts of the 
same metal vary in the irritation which they will pro- 
duce. The acid formed after the dissociation of the 
metallic ion decides the amount of irritation that the 
salt will cause. Also the greater the ease with which 
the metallic ion is dissociated from its acid ion the 
greater the corrosion; therefore, the soluble nitrates 
and chlorid are much more corrosive than the ace- 
tates, citrates and tartrates. The sulphates are between 
these groups in their irritant effect. 

The most astringent metals in the order of their 
astringency are lead, iron, aluminum, copper, zinc and 
silver. The most astringent salt is lead acetate, while 
the most irritant salts are mercuric chlorid and zinc 
chlorid. The sulphates and acetates of copper and zinc 
and the nitrates of silver and lead, if applied in weak 
solutions, are astringent, but are irritant if in large 
quantities or in strong solutions. Insoluble prepara- 
tions of mercury may irritate and corrode, but insoluble 
salts of other metals are generally only astringent. 
Double salts of the metals are less likely to irritate, 
because they ordinarily do not precipitate albumin. A 
styptic strongly coagulates albumin and hence causes a 
clot which stops hemorrhage. 



CORROSIVE POISONING 41 

SYMPTOMS 

The symptoms common to all gastro-intestinal irri- 
tants are irritation or corrosion of the mouth, throat 
and esophagus, depending on the concentration of the 
poison swallowed. Other symptoms are : more or less 
gastric pain; nausea; vomiting, first of the contents 
of the stomach, then of mucus, then often of blood; 
later diarrhea, first of the contents of the bowels, then 
mucus and, perhaps, blood are passed. There are 
more or less symptoms of shock due to the reflex 
action on the heart from irritation of the gastric 
branches of the pneumogastric nerve. The symptoms 
of collapse are a rapid, weak heart, dyspnea, cold sur- 
face of the body, clammy, cold perspiration, tendency 
to syncope, and a gradual failure of the pulse. 

The symptoms of poisoning by gastro-intestinal irri- 
tants are : 

Immediate Symptoms: Pain, nausea, vomiting, colic, diar- 
rhea and collapse. 

Frequent After-Symptoms: Inflammation and ulceration of 
the mouth, throat and esophagus, gastritis, duodenitis (jaun- 
dice), enteritis, albuminuria, nephritis, and ulceration of the 
stomach, perforation, peritonitis. 

Possible Remote Symptoms : Fatty degeneration of the 
liver, kidneys and heart; strictures after healing of the 
corrosions and ulcerations. 

TREATMENT OF CORROSIVE POISONING 

Immediate Treatment : Warm water drinks contain- 
ing the antidote, if there is one (an emetic or a stom- 
ach-tube is rarely needed and, if necessary, should be 
used with great caution and gentleness) ; albuminous 
and mucilaginous drinks, as milk, Ggg albumin, flax- 
seed infusions, slippery elm infusions, etc.; hypoder- 
matic injections of morphin sufficient to stop pain 
and continued vomiting. For corrosive acids the 
most convenient antidote is usually a solution of soap. 

Treatment of Collapse : Rest, quiet ; dry heat, espe- 
cially to the region of the heart; atropin sulphate, 
1/100 of a grain hypodermatically ; strychnin sulphate 
1/30 of a grain hypodermatically ; repeated in three 
hours, if needed (large doses of strychnin are not 
advisable, as it cannot stimulate the heart or raise 



42 NERVOUS SYSTEM IRRITANTS 

the blood-pressure as so long believed) ; camphor, a 
syringeful hypodermatically of a saturated solution in 
sterile olive oil (or a ready-prepared ampule), every 
half hour for several doses ; caffein, as strong coffee, by 
rectal injection if there is no diarrhea. 

After-Treatment: Give a saline purge, if deemed 
necessary. For acute gastritis give morphin, sufficient 
to stop the pain, mucilaginous drinks, rectal alimenta- 
tion. Give cardiac stimulants, if needed. Later give 
bismuth subcarbonate in large doses (2 grams or 30 
grains) twice a day; later, a milk diet. Treat duodeni- 
tis and nephritis, if they occur. Order absolute rest 
in bed for one or two weeks, if the irritation or cor- 
rosion was severe, lest perforation from ulceration be 
precipitated. If an ulcer of the stomach or a stricture 
occurs they must be treated as usual. 

CLASS II. — IRRITANTS OF THE CENTRAL NERVOUS 
SYSTEM 

The principal symptoms of poisoning by drugs of 
this class are those of irritation of the central nervous 
system. There is restlessness and nervous excitement ; 
there may be, later, delirium and convulsions and, 
perhaps, still later, coma. The pulse is full, bounding, 
and generally rapid ; there may even be delirium cordis 
or tachycardia. Respirations are increased in rapidity, 
the face is flushed and the skin of the body feels hot 
and dry, and there often is increased temperature. 
There may be vomiting; there often is diarrhea; there 
is vesical irritability, and often strangury, depending 
on the drug. Some drugs of the atropin series may 
cause vesical paresis. There are muscular twitchings; 
there may be cramps; and, as above stated, convul- 
sions may occur. The pupils are of course dilated if 
the poisoning is by any member of the atropin series 
or by cocain, and they often become dilated during 
cerebral excitement from other members of this group. 

The symptoms of poisoning by irritants of the cen- 
tral nervous system are: 

Immediate Symptoms : Gastro-intestinal burning and pain, 
perhaps nausea and vomiting, if the poison contains an aro- 



TREATMENT OF POISONING 43 

matic or volatile oil; cerebral excitement, rapid heart, rapid 
respiration, erythemas and flushing of the face and surface of 
the body. 

Frequent After-Symptoms: Purging, frequent urination, 
muscular twitchings, delirium, convulsions, coma and failure 
of the circulation. 

Possible Remote Symptoms : Abortion in pregnant women ; 
albuminuria and nephritis if the poison is a renal irritant as 
are many of the volatile oils; prolonged sleeplessness and 
nervous irritability 

TREATMENT OF POISONING BY IRRITANTS OF THE 
CENTRAL NERVOUS SYSTEM 

Administer warm water with the antidote, if there 
is such. 

Give an emetic. The emetics in the order of their 
strength are: mustard (a tablespoonful in a glass of 
warm water) ; ipecac (2 gm. [30 grains] of powdered 
ipecac, or a tablespoonful of the syrup) ; zinc sulphate 
(2 gm. [30 grains] dissolved in water) ; copper sul- 
phate (0.50 gram [7y 2 grains] dissolved in water) ; 
apomorphiti (1/10 of a grain given hypodermatically). 
Any of these emetics may be repeated in fifteen min- 
utes if there is no satisfactory result. It should be 
remembered that apomorphin is depressant to the cir- 
culation. 

Wash out the stomach by means of a stomach-tube, 
if there is no satisfactory emesis. If the vomiting is 
satisfactory, continue to administer warm water until 
the stomach washes clean. 

Administer one or more nerve sedatives. The best 
are bromids and chloral, and the dose depends on the 
character of the poison. They are best administered 
by the rectum, at least provided nausea and vomiting 
is continued after the stomach has been cleared of the 
poison. If there is much circulatory depression, the 
best sedative to administer is morphin, hypodermati- 
cally, perhaps combined with scopolamin (hyoscin). 
■ An adjunct to the action of the morphin as a central 
nervous sedative and as a strengthener of the circula- 
tion is ergot, given intramuscularly. If there are con- 
vulsions, inhalations of chloroform are required. 

Apply' dry heat to the body, if the surface is cool or 
there is a tendency to collapse. 



44 NERVOUS SYSTEM DEPRESSANTS 

If heart failure occurs later in the poisoning, from 
shock or from the depression caused by nausea, such 
circulatory stimulants should be given as camphor (a 
saturated solution in olive oil hypodermatically) ; 
strophanthin (given hypodermatically or intravenously 
in a dose of 1/500 of a grain) ; epinephrin in aseptic 
ampule or 1 c.c, 15 minims, of a 1 part to 10,000 
solution; or intramuscular injection of some aseptic 
ergot preparation (1 ampule) and repeat in an hour, 
if needed. 

Give plenty of water with a demulcent, if there has 
been irritation of the stomach either from a volatile 
oil poisoning or from the emetic used. 

CLASS III. DEPRESSANTS OF THE NERVOUS AND 

CIRCULATORY SYSTEM 

The symptoms of poisoning by drugs of this class 
are, as their name implies, those of circulatory and 
nervous depression. The pulse is either slow or rapid, 
but generally weak ; the surface of the body generally 
becomes cold ; respirations are slowed ; pupils are gen- 
erally dilated unless the poison is morphin or nicotin ; 
often the patient becomes faint; drowsiness soon devel- 
ops, and if a narcotic has been taken stupor soon devel- 
ops; perhaps convulsions will occur; later paralysis 
and coma. 

Immediate Symptoms (if the poison is a depressant of the 
nervous system) : Depression, drowsiness, slow, weak pulse; 
slowed respiration, paralysis, and coma. 

Later Symptoms: Muscular weakness and circulatory 
weakness. 

Immediate Symptoms (if the poison is a circulatory depres- 
sant) : Rapid or slow, weak pulse ; cardiac anxiety ; cold, 
clammy perspiration; face pale; perhaps convulsions, and 
syncope. 

TREATMENT 

Wash out the stomach (emetics or stomach tube, as 
see above). 

Administer not only the chemical but a physiologic 
antidote, if there is such. 

Apply dry heat to the body. 



NERVOUS SYSTEM DEPRESSANTS 45 

If the poison was a narcotic, give cerebral and 
nervous stimulation, as caffein (coffee), camphor, 
atropin, strychnin. 

If the poison was a circulatory depressant, give 
atropin, ergot, epinephrin or strophanthin, as above 
described. 

Compel prolonged mental, circulatory and physical 
rest. 

The accompanying table is arranged alphabetically. 

The second column gives the class to which the 
poison belongs, and the treatment for this class has 
been given under the headings of the general treatment 
for each class. Therefore the number of the class to 
which the poison belongs refers to the treatment there 
outlined. 

Column 3 ("special symptoms") suggests symptoms 
of poisoning which are characteristic of the drug, such 
symptoms being in addition to those which are charac- 
teristic of the class of poisons to which the drug 
belongs. 

In the fourth column ("special treatment") is indi- 
cated any chemical or physiologic antidote that is valu- 
able in treating poisoning by the drug, and is an addi- 
tion to the general rules discussed above. 



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USEFUL DRUGS 



A book has been prepared by the Council on Phar- 
macy and Chemistry, entitled "Useful Drugs." It 
discusses a selected list of remedies, including only 
those drugs which usage has proved are efficient and 
reliable. A list of these drugs follows : 

Acacia. — Acacia, U. S. P. 

Mucilago Acaciae. — Mucilage of Acacia, U. S. P, 
Aeetanilidum. — Acetanilid, U. S. P. Dosage: 0.20 gm. or 3 grains. 
Acetphenetidinum.— Acetphenetidin, U. S. P. Dosage: 0.30 gm. or 5 

grains. 
Acidum Aceticum. — Acetic Acid, U. S. P. 

Diluted Acetic Acid, U. S. P. 
Acidum Acetylsalicylicum. — Aspirin. Dosage: 0.3 to 0.6 or 5 to 10 grains. 
Acidum Benzoicum. — Benzoic Acid, U. S. P. Dosage: 0.5 gm. or 8 grains. 
Acidum Boricum. — Boric Acid. 

Glyceritum Boroglycerini. — Glycerite of Boroglycerin, U. S. P. 

Unguentum Acidi Borici. — Ointment of Boric Acid, U. S. P. 
Acidum Citricum. — Citric Acid, IJ. S. P. Dosage: 0.5 gm. or 8 grains. 
Acidum Hydrochloricum. — Hydrochloric Acid, U. S. P. 

Acidum Hydrochloricum Dilutum. — Diluted Hydrochloric Acid, U. S. P. 
Dosage : 1 c.c. or 15 minims. 
Acid Nitricum.— Nitric Acid, U. S. P. 
Acidum Phenylcinchoninicum. — See Cinehophen, N. N. R. 
Acidum Picricum. — See Trinitrophenol. 
Acidum Salicylicum. — Salicylic Acid, U. S. P. 
Acidum Tannicum. — Tannic Acid, U. S. P. Dosage: 0.5 gm. or 8 grains. 

Glyceritum Acidi Tannici. — Glycerite of Tannic Acid, U. S. P. Dosage: 
2 c.c. or 30 minims. 

Tannalbin. — Tannalbin, N. N. R. Dosage: 2 gm. or 30 grains. 
Aconitum. — Aconite, U. S. P. 

Tinctura Aconiti — Tincture of Aconite, U. S. P. Dosage : 0.2 c.c. or 3 
minims. 
Adeps.— Lard, U. S. P. 

Adeps Benzoinatus. — Benzoinated Lard, U. S. P. 
Adeps Lanae Hydrosus. — Hydrous Wool Fat, U. S. P. 
Adrenalin. — See Epinephrine. 
Aether. — Ether, U. S. P. Dosage : 1 c.c. or 15 minims. 

Spiritus Aetheris, U. S. P. Dosage: 4 c.c. or 1 fluidram. 

Aether Nitrosus. — Used only in the form of 

Spiritus Aetheris Nitrosi. — Spirit of Nitrous Ether, U. S. P. Dosage: 
2 c.c. or 30 minims. 
Aethylis Chloridum.— Ethyl Chloride, U. S. P. 
Aethyl-Morphinae Hydrochloridum. — Ethyl-Morphin Hydrochloride, N. N. 

R. Dionin. Dosage : 0.015 gm. or % grain. 
Alcohol.— Alcohol, U. S. P. 

Elixir Aromatieum. — Aromatic Elixir, U. S. P 
Aloes. — Aloe, U. S. P. Dosage: 0.15 to 0.3 gm. or 2 to 5 grains, purgative; 
0.03 to 0.05 gm. or V 2 to 1 grain, laxative. 

Extractum Aloes.— Extract of Aloes, U. S. P. Dosage: 0.125 gm. or 2 
grains- 

Aloinum— Aloin, U. S. P. Dosage: 0.015 gm. or % grain. 
Alumen. — Alum, U. S. P. 

Alumen Exsiccatum. — Exsiccated Alum, U. S. P. 



USEFUL DRUGS 51 

Alumini Acetas. — Aluminum Acetate. 

Liquor Alumini Acetatis.— Solution of Aluminum Acetate, N. F. 
Ammonia. 
Aqua Ammoniae. — Ammonia Water, U. S. P. 
Linimentum Ammoniae. — Ammonia Liniment, U. S. P. 
Ammonii Carbonas— Ammonium Carbonate, U. S. P. Dosage: 0.3 gm. 
or 5 gTains. 
Spiritus Ammoniae Aromaticus. — Aromatic Spirit of Ammonia, U. S. P. 
Dosage : 1 to 5 c.c. or 15 to 60 minims. 
Ammonii Chloridum.— Ammonium Chloride, U. S. P. Dosage: 0.30 to 1 

gm. or 5 to 15 grains. 
Amylis Nitris.— Amyl Nitrite, U. S. P. Dosage: 0.2 c.c. or 3 minims, by 

inhalation. 
Amylum. — Starch, Corn Starch, U. S. P. 
Antimonii et Potassii Tartras. — Antimony and Potassium Tartrate, U. S. P. 

Dosage: 0.001 gm. or 1/60 grain. 
Antipyrina. — Antipyrine, U. S. P. Dosage : 0.25 gm. or 4 grains 
Apomorphinae Hydrochloridum. — Apomorphine Hydrochloride, U. S. P. 
Dosage : expectorant 0.002 gm. or 1/30 grain, emetic 0.0005 gm. or 
1/10 grain. 
Aqua.— Water, U. S. P. 

Aqua Destillata.— Distilled Water, U. S. P. 
Argenti Nitras. — Silver Nitrate, U. S. P. Dosage: 0.01 gm. or 1/5 grain 

Argenti Nitras Fusus. — Molded Silver Nitrate, U. S. P. 
Argenti Prpteinas. — Silver Proteinate. See Argyrol and Protargol, N. N. R. 
Aristol. — See Thymolis Iodidum. 

Arseni Trioxidum. — Arsenic Troixide, U. S. P. Dosage: 0.002 gm. or 
1/30 grain. 
Liquor Acidi Arsenosi. — Solution of Arsenous Acid, U. S. P. Dosage : 

0.2 c.c. or 3 minims. 
Liquor Arseni et Hydrargyri lodidi. — Solution of Arsenous and Mercuric 

Iodids, U. S. P. Dosage: 0.1 c.c. or 1*4 minims. 
Liquor Potassii Arsenitis. — Solution of potassium Arsenite, U. S. P. 
Dosage : 0.2 c.c. or 3 minims. 
Arsphenamina. — Arsphenamin, N. N. R. Dosage: 0.3 to 0.6 gm. or 5 to 9 
grains. 
Neoarsphenamina. — Neoarsphenamin, N. N. R. Dosage: 0.6 to 0.9 gm. 
or 9 to 14 grains. 
Asafoetida. — Asafetida, U. S. P. Dosage : 0.25 gm. or 4 grains. 
Aspidium. — Aspidium, U. S. P. 
Oleoresina Aspidii. — Oleoresin of Aspidium, U. S. P. Dosage : 2 gm. 
or 30 grains. 
Aspirin. — Aspirin, N. N. R. Dosage : 0.3 to 1 gm. or 5 to 15 grains. 
Atophan. — See Cincophen, N. N. R. 

Atropina. — Atropine, U. S. P. Dosage : 0.00025 gm. or 1/250 gr. 
Atropfnae Sulphas. — Atropine Sulphate, U. S. P. Dosage: 0.4 mg." or 
1/160 grain. 
Balsamum Peruvianum. — Balsam of Peru, U. S. P. 
Balsamum Tolutanum. — Balsam of Tolu, U. S. P. 
Syrupus Tolutanus. — Syrup of Tolu, U. S. P. Dosage: 16 c.c. or 4 
fluidrams. 
Barbital. — Barbital, N. N. R. Dosage : 0.3 to 0.6 gm. or 5 to 10 grains. 
Barbital Sodium. — Sodii Barbital, N. N. R. Dosage: 0.3 to 0.6 gm. or 
5 to 10 grains. 
Belladonnae Folia. — Belladonna Leaves, U. S. P. 
Tinctura Belladonnae Foliorum. — Tincture of Belladonna Leaves, U. S. 

P. Dosage : 0.5 c.c. or 8 minims. 
Extractum Belladonnae Foliorum. — Extract of Belladonna Leaves, U. S. 

P. Dosage : 0.01 gm. or 1/5 grain. 
Emplastrum Belladonnae. — Belladonna Plaster, U. S. P. 
Unguentum Belladonnae. — Belladonna Ointment, U. S. P. 



52 USEFUL DRUGS 

Benzoinum. — Benzoin, U. S. P. 
Tinctura Benzoinae Composita.— Compound Tincture of Benzoin, 
U. S. P. 
Benzosulphinidum. — Benzosulphinide, Saccharin, U. S. P. Dosage: 0.2 

gm. or 3 grains. 
Betanaphthol. — Betanaphthol, U. S. P. Dosage: 0.1 to 0.3 gm. or 2 to 

5 grains. 
Bismuthi Subcarbonas. — Bismuth Subcarbonate, U. S. P. Dosage: 1 gm. 

or 15 grains. 
Bismuthi Subgailas. — Bismuth Subgallate, U. S. P. Dosage: 0.25 gm. or 

4 grains. 
Bismuthi Subnitras. — Bismuth Subnitrate, U. S. P. Dosage: 1 gm. or 15 

grains. 
Bismuthi Subsalicylas. — Bismuth Subsalicylate, U. S. P. Dosage: 0.25 

gm. or 4 grains. 
Caffeina. — Caffeine, U. S. P. Dosage: 0.06 gm. to 0.3 gm. or 1 to 5 grains. 
Caffeina Citrata. — Citrated Caffeine, U. S. P. Dosage: 0.1 gm. or 2 
grains. 
Caffeinae Sodio-Benzoas. — Caffeine Sodio-Benzoate, N. F. Dosage: 0.10 

gm. or 2 grains. 
Calcii Carbonas Praecipitatus. — Precipitated Calcium Carbonate, U. S. P. 

Dosage : 1 to 3 gm. or 15 to 45 grains. 
Calcii Chloridum.— Calcium Chloride, U. S. P. Dosage: 0.5 gm. or 7% 

grains. 
Calcii Lactas. — Calcium Lactate, N. N. K. Dosage : 0.5 gm. or iy 2 grains. 
Calx! — Calcium Oxide, U. S. P. 
Liquor Calcis. — Solution of Calcium Hydroxide, U. S. P. Dosage : 15 

c.c. or 4 fluidrams. 
Linimentum Calcis. — Lime Liniment, U. S. P. 
Calx Chlorinata. — Chlorinated Lime, Chlorinated Calcium Oxide, U. S. P. 
Liquor Sodae Chlorinatae. — Solution of Chlorinated Soda, U. S. P. 
Dosage : 1 c.c. or 15 minims. 
Camphora. — Camphor, U. S. P. Dosage : 0.10 gm. or about 2 grains. 
Aqua Camphorae. — Camphor Water, U. S. P. Dosage : 10 c.c. or 2 

fluidrams. 
Spiritus Camphorae. — Spirit of Camphor, U. S. P. Dosage : 1 c.c. or 

15 minims. 
Linimentum Camphorae. — Camphor Liniment, U. S. P. 
Cantharis. — Cantharides, U. S. P. 
Ceratum Cantharidis. — Cantharides Cerate, U. S. P. 
Tinctura Cantharidis, U. S. P. — Dosage : 0.1 c.c. or iy 2 minims. 
Capsicum. — Capsicum, U. S. P. Dosage : 0.05 gm. or about 1 grain. 
Tinctura Capsici. — Tincture of Capsicum, U. S. P. Dosage : 0.5 c.c. 
or 7% minims. 
Carbo Ligni. — Charcoal, U. S. P. Dosage : 1 gm. or 15 grains. 
Cardamomum. — Cardamom, U. S. P. 
Tinctura Cardamomi. — Tincture of Cardamom. Dosage: 5 c.c. or 1 
fluidram. 
Caryophyllus. — Cloves, U. S. P. 
Oleum Caryophylli. — Oil of Cloves, TJ. S. P. Dosage: 0.2 c.c. or 3 
minims. 
Cascara Sagrada, Cascara Sagrada, U. S. P. 

Fluidextractum Cascarae Sagradae. — Fluidextract of Cascara Sagrada, 

U. S. P. Dosage : 1 c.c. or 15 minims. 
Fluidextractum Cascarae Sagradae Aromaticum — Aromatic Fluidextract 

of Cascara Sagrada, U. S. P. Dosage : 2 c.c. or 10 to 30 minims. 
Extractum Cascarae Sagradae. — Extract of Cascara Sagrada, U. S. P. 
Dosage : 5 gm. or 2 to 8 grains. 
Cera Alba. — White Wax, U. S. P., is the bleached form of 

Cera Flava. — Yellow Wax, U. S. P. 
Chenopodii Oleum. — Oil of Chenopodium, U. S. P. Dosage : 0.2 c.c. or 3 
minims. 



USEFUL DRUGS 53 

Chloralum Hydratum.— Hydrated Chloral, U. S. P. Dosage: 0.30 to 1.30 

gm. or 5 to 20 grains. 
Chloramin-T. — Sodium Paratoluenesulphochloramid, N. N. R. 
Chloroform. — Chloroform, U. S. P. Dosage: 0.05 to 0.3 c.c. or 1 to 5 
minims. 
Aqua Chloroformi. — Chloroform Water, U. S. P. Dosage: 15 c.c. or 

4 fluidrams. 
Spiritus Chloroform!. — Spirit of Chloroform, U. S. P. Dosage : 2 c.c. 

or 30 minims. 
Linimentum Chloroformi. — Chloroform Liniment, U. S. P. 
Chromii Trioxidum. — Chromium Trioxide, U. S. P. 
Chrysarobinum. — Chrysarobin, U. S. P. 

Unguentum Chrysarobini. — Chrysarobin Ointment, U. S. P. 
Cinchona. — Cinchona, TJ. S. P. 
Tinctura Cinchonae. — Tincture of Cinchona, U. S. P. Dosage : 4 c.c. 

or 1 fluidram. 
Tinctura Cinchonae Composita. — Compound Tincture of Cinchona, U. S. 
P. Dosage : 4 c.c. or 1 fluidram. 
Cinnamomum. — Cinnamon, U. S. P. 

Oleum Cassiae. — Oil of Cinnamon, TJ. S. P. Dosage : 0.05 c.c. or 1 

minim. 
Aqua Ctanamomi. — Cinnamon Water, U. S. P. Dosage: 15 c.c. or 4 
fluidrams. 
Cocaina. — Cocaine, U. S. P. Dosage : 0.03 gm. or y 2 grain. 
Cocaina Hydrochloridum. — Cocaine Hydrochloride, U. S. P. Dosage: 

0.03 gm. or y 2 grain. 
Codeina. — Codeine, U. S. P. Dosage : 0.03 gm. or y 2 grain. 
Codeinae Phosphas. — Codeine Phosphate, U. S. P. Dosage : 0.03 gm. or 

*6 grain. , 

Codeinae Sulphas. — Codeine Sulphate, U. S. P. Dosage: 0:03 gm. or Vz 

grain. 
Colchici Semen. — Colchicum Seed, TJ. S. P. 
Tinctura Colchici Seminis. — Tincture of Colchicum Seed, TJ. S. P. 
Dosage : 2 c.c. or 30 minims. 
Collodium. — Collodion, TJ. S. P. 

Collodium Flexile.— Flexible Collodion, TJ. S. P. 
Colocynthis.— Colocynth, TJ. S. P. 

Extractum Colocynthidis. — Extract of Colocynth, TJ. S. P. Dosage : 

0.03 gm. or % grain. 
Extractum Colocynthidis Compositum. — Compound Extract of Colocynth, 
TJ. S. P. Dosage: 0.5 gm. or iy 2 grains. 
Copaiba. — Copaiba, TJ. S. P. Dosage : 1 c.c. or 15 minims. 
Creosotum. — Creosote, TJ. S. P. Dosage : 0.2 c.c. or 3 minims. 
Cresol. — Cresol, TJ. S. P. Dosage : 0.05 c.c. or 1 minim. 
Liquor Cresol is Compositus. — Compound Solution of Cresol, TJ. S. P. 
Dosage : Solutions containing 1 to 5 per cent. 
Cupri Sulphas. — Copper Sulphate, TJ. S. P. Dosage : 0.01 gm. or 1/5 

grain, astringent; 0.3 gm. or 5 grains (not repeated), emetic. 
Dichloramin-T. — Paratoluenesulphondichloramid. N. N. R. 
Digitalis. — Digitalis, TJ. S. P. Dosage : 0.065 gm. or 1 grain. 
Infusum Digitalis. — Infusion of Digitalis, TJ. S. P. Dosage: 8 c.c. or 

2 fluidrams. 
Tinctura Digitalis. — Tincture of Digitalis, TJ. S. P. Dosage: 1 c.c. or 
15 minims. 
Diphtheria Antitoxin. — See Serum Antidiphthericum. 
Elaterinum. — Elaterin, TJ. S. P. Dosage: 0.005 gm. or 1/10 grain. 

Trituratio Elaterini. — Dosage : 0.03 gm. or y 2 grain. 
Emetinae Hydrochloridum. — Emetine Hydrochloride, TJ. S. P. Dosage : 
0.03 to 0.45 gm. or from % to % grain as an amebicide ; 1/12 to 
1/16 grain as an expectorant. 
Epinephrine.— Epinephrine, N. N. R. Dosage : 1 : 10,000 to 1 : 1,000. 
Internally, 5 to 10 drops of 1 :1,000 solution. 



54 USEFUL DRUGS 

Ergota. — Ergot, U. S. P. Dosage : 2 gm. or 30 grains. 
Fluidextractum Ergotae. — Flutdextract of Ergot, U. S. P. Dosage : 
2 c.c. or 30 minims. 
Eucalyptus.— Eucalyptus, U. S. P. 

Eucalyptol. — Eucalyptol, U. S. P. Dosage : 0.3 c.c. or 5 minims. 
Oleum Eucalypti. — Oil of Eucalyptus, U. S. P. Dosage: 0.5 c.c. or 8 
minims. 
Fel Bovis.— Oxgall, TJ. S. P. 

Extractum Fellis Bovis. — Extract of Oxgall, U. S. P.. Dosage: 0.1 gra. 
or 1% grains. 
Ferri Carbonas. — Ferrous Carbonate. 

Mass a Ferri Carbon atis. — Mass of Ferrous Carbonate, U. S. P. Dosage: 

0.25 gm. or 4 grains. 
Pilulae Ferri Carbonatis. — Pills of Ferrous Carbonate, U. S. P. Dosage : 
2 pills. 
Ferri Chloridum.— Ferric Chloride, XJ. S. P. 
Tinctura Ferri Chloridi. — Tincture of Ferric Chloride, U. S. P. Dosage : 
0.5 c.c. or 8 minims. 
Ferri et Ammonii Citras. — Iron and Ammonium Citrate, U. S. P. Dosage : 

0.25 gm. or 4 grains. 
Ferri lodidum. — Ferrous Iodide. 
Syrupus Ferri lodidi. — Syrup of Ferrous Iodide, U. S. P. Dosage : 
1 c.c. or 15 minims. 
Ferri Phosphas Solubilis.— Soluble Ferric Phosphate, U. S. P. Dosage : 

0.25 gm. or 4 grains. 
Ferri Sulphas. — Ferrous Sulphate, U. S. P. Dosage: 0.2 gm. or 3 grains. 

Ferri Sulphas Exsiccatus. — Exsiccated Ferrous Sulphate, U. S. P. 
Ferrum. — Iron, U. S. P. 

Ferrum Reductum. — Reduced Iron, U. S. P. Dosage: 0.06 gm. or 1 
grain. 
Formaldehydum. — Formaldehyde. 

Liquor Formaldehydi. — Solution of Formaldehyde, U. S. P. 
Gelatinum. — Gelatin, U. S. P. 
Gentiana. — Gentian, U. S. P. 
Tinctura Gentianae Composita. — Compound Tincture of Gentian. U. S. P. 

Dosage : 4 c.c. or 1 fluidram. 
Extractum Gentianae. — Extract of Gentian, U. S. P. Dosage : 0.25 gm. 
or 4 grains. 
Glycerinum. — Glycerin, TJ. S. P. 

Suppositoria Glycerini. — Suppositories of Glycerin, TJ. S. P. 
Glycerylis Nitras.— Glyceryl Trinitrate. 
Spiritus Glycerylis Nitratis. — Spirit of Glyceryl Trinitrate, TJ. S. P. 
Dosage : 0.05 c.c. or 1 minim 
Glycyrrhiza. — Glycyrrhiza, Licorice Root, TJ. S P. 
Fluidextractum Glycyrrhizae. — Fluidextract of Glycyrrhiza, TJ. S. P. 

Dosage : 2 c.c. or 30 minims. 
Pulvis Glycyrrhizae Compositus. — Compound Powder of Glycyrrhiza, 
TJ. S. P. Dosage : 4 gm. or 60 grains. 
Guaiacol.— Guaiacol, TJ. S. P. Dosage: 0.1 to 0.6 c.c. or 1% minims 

to 10 minims. 
Guaiacolis Carbonas. — Guaiacol Carbonate, TJ. S. P. Dosage : 1 gm. or 

15 grains. 
Hexamethylenamina. — Hexamethylenamine, TJ. S. P. Dosage: 0.3 gm. 

or 5 grains. 
Homatropinae Hydrobromidum. — Homatropine Hydrobromide, TJ. S. P. 

Dosage : 0.0005 gm. or 1/125 grain. 
Hydrargyri Chloridum Corrosivum. — Corrosive Mercuric Chloride. TJ. S. P. 

Dosage: 0.002 to 0.01 gm. or 1/30 to 1/6 grain. 
Hydrargyri Chloridum Mite. — Mild Mercurous Chloride, TJ. S. P. Dosage: 

0.005 to 0.02 gm. or 1/10 to 1/3 grain. 
Hydrargyri lodidum Flavum. — Yellow Mercurous Iodide, TJ. S. P. Dosage : 
0.015 gm. or % grain. 



USEFUL DRUGS - 55 

Hydrargyri lodidum Rubrum. — Red Mercuric Iodide, U. S. P. Dosage : 

0.003 or 1/20 grain. 
Hydrargyri Oxidum Flavum. — Yellow Mercuric Oxide, U. S. P. Dosage: 
0.5 to 2 per cent, ointment. 
Unguentum Hydrargyri Oxidi Flavi. — Ointment of Yellow Mercuric 
Oxide, U. S. P. Dosage : It should be diluted with from 10 to 100 
parts of petrolatum. 
Hydrargyri Salicylas. — Mercuric Salicylate, N. N. R. Dosage: 0.6 c.c. or 

10 minims of a 10 per cent, suspension in liquid paraffin. 
Hydrargyrum. — Mercury, U. S. P. 

Hydrargyrum cum Creta. — Mercury with Chalk, U. S. P. Dosage : 0.250 
gm. or 4 grains. 
Massa Hydrargyri. — Mass of Mercury, U. S. P. Dosage: 0.250 gm. or 

4 grains. 
Unguentum Hydrargyri. — Mercurial Ointment, U. S. P. 
Unguentum Hydrargyri Dilutum. — Blue Ointment, U. S. P. Dosage: 2 
gm. or 30 grains. 
Hydrargyrum Ammoniatum. — Ammoniated Mercury, U. S. P. 
Unguentum Hydrargyri Ammoniati. — Ointment of Ammoniated Mercury, 
U. S. P 
Hydrastininae Hydrochloridum. — Hydrastinin Hydrochlorid, U. S. P. 

Dosage 0.03 gm. or y 2 grain. 
Hydrastis. — Hydrastis, U. S. P. 

Fiuidextractum Hydrastis. — Fluidextract of Hydrastis, U. S. P. Dosage: 
2 c.c. or 30 minims. 
Hydrogen ii Dioxidum. — Hydrogen Dioxide. 

Liquor Hydrogenii Dioxidi. — Solution of Hydrogen Dioxide, U. S. P. 
Dosage : Apply diluted with four volumes of water. 
Hyoscyamus. — Hyoscyamus, U. S. P. 
Tinctura Hyoscyami. — Tincture of Hyoscyamus, U. S. P. Dosage : 0.6 
to 2 c.c. or 10 to 30 minims. 
Hypophysis Sicca. — Dessicated Hypophysis, U. S. P. 

Liquor Hypophysis. — Solution of Hypophysis, U. S. P. Dosage: 1 c.c. 
or 15 minims. 
Ichthyol.— Ichthyol, N. N. R. Dosage: 0.2 to 2 c.c. of 3 to 30 minims. 
lodoformum. — Iodoform, U. S. P. Dosage: 0.25 gm. or 4 grains. 
lodum. — Iodine, U. S. P. 
Tinctura lodi. — Tincture of Iodine, U. S. P. Dosage: 0.1 c.c. or 1% 
minims. 
Ipecacuanha. — Ipecac, U. S. P. Dosage: 0.05 gm. or 1 grain, expectorant; 
1 gm. or 15 grains, emetic. 
Fiuidextractum Ipecacuanhae. — Fluidextract of Ipecac, U. S. P. Dosage: 

1 c.c. or 15 minims, emetic; 0.05 c.c. or 1 minim, expectorant. 
Syrupus Ipecacuanhae. — Syrup of Ipecac, U. S. P. Dosage: 0.25 c.c. 
or 4 minims, expectorant; 15 c.c. or 4 fluidrams, emetic. 
Jalapa. — Jalap, U. S. P. Dosage : 1 gm. or 15 grains. 

Pulvis Jalapae Compositus.— Compound Powder of Jalap, U. S. P. 
Dosage : 2 gm. or 30 grains. 
Lin urn. — Flaxseed, U. S. P. 

Oleum Lini. — Linseed Oil, U. S. P. Dosage : 30 c.c. or 1 fluidounce. 
Lobelia. — Lobelia, U. S. P. 
Tinctura Lobeliae. — Tincture of Lobelia, U. S. P. Dosage : 0.5 c.c. to 
1.5 c.c. or 10 to 20 minims. 
Magnesii Carbonas. — Magnesium Carbonate, U. S. P. Dosage : 3 gm. or 

45 grains. 
Magnesii Citras. — Magnesium Citrate. 

Liquor Magnesii Citratis. — Solution of Magnesium Citrate, U. S. P. 
Dosage : 360 c.c. or 12 fluidounces. 
Magnesii Oxidum. — Magnesium Oxide, U. S. P. Dosage: 0.6 to 3 gm. 

or 10 to 45 grains. 
Magnesii Sulphas. — Magnesium Sulphate, V. S. P. Dosage : 15 gm. or 
240 grains. 



56 USEFUL DRUGS 

Mentha Piperita. — Peppermint, U. S. P. 
Oleum Menthae Piperitae.— Oil of Peppermint, U. S. P. Dosage: 0.2 

c.c. or 3 minims. 
Spiritus Menthae Piperitae.— Spirit of Peppermint, U. S. P. Dosage : 2 

c.c. or 30 minims. 
Aqua Menthae Piperitae. — Peppermint Water, U. S. P. Dosage: 16 
c.c. or 4 fluidrams. 
Menthol. — Menthol, U. S. P. Dosage : 0.065 gm. or 1 grain. 
Methylis Salicylas. — Methyl Salicylate, U. S. P. Dosage: 1 c.c. or 15 

minims. 
Morphina. — Morphine, U. S. P. Dosage: 0.01 gm. or 1/6 grain. 
Morphinae Hydrochloridum. — Morphine Hydrochloride, U. S. P. Dosage: 

0.01 gm. or 1/6 grain. 
Morphinae Sulphas. — Morphine Sulphate, U. S. P. Dosage: 0.01 gm. 
or 1/6 grain. 
Myrrha. — Myrrh, TJ. S. P. Dosage: 0.5 gm. Or 7^ grains. 
Tinctura Myrrhae. — Tincture of Myrrh, U. S. P. Dosage: 1 c.c. or 
15 minims. 
Novocain. — See Procain. 
Nux Vomica.— Nux Vomica, U. S. P. 

Extractum Nucis Vomicae. — Extract of Nux Vomica, U. S. P. Dosage: 

0.015 gm. or % grain 
Tinctura Nucis Vomicae. — Tincture of Nux Vomica, U. S. P. Dosage: 
0.6 c.c. or 10 minims. 
Oleum Moorhuae. — Cod-Liver Oil, U. S. P. Dosage: 4 to 30 c.c. or 1 

dram to 1 fluidounce. 
Oleum Ricini. — Castor Oil, TJ. S. P. Dosage: 15 c.c. or 4 fluiddrams. 
Oleum Santali. — Oil of Santal, U. S. P. Dosage : 0.5 c.c. or 8 minims. 
Oleum Theobromatis. — Oil of Theobroma, U. S. P. Cacao Butter. 
Oleum Tiglii. — Croton Oil, U. S. P. Dosage: 0.05 c.c. or 1 minim. 
Opium. — Opium, U. S. P. 

Opii Pulvis. — Powdered Opium, U. S. P. Dosage : 0.065 gm. or 1 grain. 
Extractum Opii.— Extract of Opium, U. S. P. Dosage: 0.03 gm. or y 2 

grain. 
Tinctura Opii. — Tincture of Opium, Laudanum, U. S. P. Dosage : 0.5 

c.c. or 8 minums. 
Tinctura Opii Deodorati. — Tinctura of Deodorized Opium, U. S. P: 

Dosage : 0.5 c.c. or 8 minims 
Tinctura Opii Camphorata. — Camphorated Tincture of Opium, Paregoric, 

U. S. P. Dosage : 8 c.c. or 2 fluidrams. 
Pulvis Ipecacuanhas et Opii. — Powder of Ipecac and Opium, U. S. P. 
Dosage: 0.5 gm. or 7y 2 grains. 
Oxygenium. — Oxygen, U. S. P. 

Pancreatinum. — Pancreatin, U. S. P. Dosage: 0.5 gm. or 7y 2 grains. 
Paraffin urn. — ParafQn, U. S. P. 

Paraldehydum. — Paraldehyde, U. S. P. Dosage : 2 c.c. or 30 minims. 
Pelletierinae Tannas. — Pelletierine Tanuate, TJ. S. P. Dosage: 0.25 gm. 

or 4 grains. 
Pepsinum. — Pepsin, TJ. S. P. Dosage: 0.25 gm. or 4 grains. 
Petrolatum. — Petrolatum, TJ. S. P. 

Petrolatum Liquidum. — Liquid Petrolatum, TJ. S. P. 
Phenol.— Phenol, TJ. S. P. 

Phenol Liquefactum— Liquefied Phenol, TJ. S. P. Dosage: 0.05 c.c. or 
1 minim. 
Phenolphthalein. — Phenolphthalein, N. N. R. Dosage: 0.05 to 0.5 gm. 

or 1 to 8 grains. 
Phenylis Salicylas.— Phenyl Salicylate, TJ. S. P. Dosage: 0.2 to 0.5 gm. 

or 3 to 8 grains. 
Phosphorus. — Phosphorus, TJ. S. P. Dosage: 0.5 mg. or 1/125 grain. 
Physostigma. — Physostigma, TJ. S. P. 

Physostigminae Salicylas. — Physostigmine Salicylate, TJ. S. P. Dosage: 
1 mg. or 1/60 grain. 



USEFUL DRUGS 57 

Pilocarpus. — Pilocarpus, U. S. P. 

Pilocarpinae Hydrochloridum. — Pilocarpine Hydrochloride, U. S. P. 

Dosage : 1.001 to 0.01 gm. or 1/60 to 1/6 grain. 
Pilocarpinae Nitras. — Pilocarpine Nitrate, U. S. P. Dosage : 0.1 gm. 

or 1/5 grain. 
Pix Liquida. — Tar, U. S. P. 

Unguentum Picis Liquidae. — Tar Ointment, U. S. P. 
Plumbi Acetas.— Lead Acetate, U. S. P. Dosage: 0.065 gm. or 1 grain. 

Liquor Plumbi Subacetatis. — Solution of Lead Subacetate, U. S. P. 
Podophyllum.— Podophyllum, U. S. P. 

Resina Podophylli. — Resin of Podophyllum, U. S. P. Dosage : 0.003 

to 0.006 gm. or 1/20 to 1/10 grain. 
Potassii Acetas. — Potassium Acetate, U. S. P. Dosage : 2 gm. or 30 

grains. 
Potassii Bicarbonas. — Potassium Bicarbonate, U. S. P. Dosage : 2 gm. 

or 30 grains. 
Potassii Bitartras. — Potassium Eitartrate, U. S. P. Dosage : 2 gm. or 30 

grains. 
Potassii Bromidum. — Potassium Bromide, U. S. P. Dosage: 1 gm. or 15 

grains. 
Potassii Carbonas. — Potassium Carbonate, U. S. P. Dosage: 1 gm. or 15 

grains, well diluted. 
Potassii Chloras. — Potassium Chlorate, U. S. P. Dosage: Saturated solu- 
tion may be used as mouth wash or gargle. 
Potassii Citras. — Potassium Citrate, U. S. P. Dosage : 1 gm. or 15 grains. 
Potassii Citras Effervescens. — Effeorescent Potassium Citrate, U. S. P. 

Dosage : 4 gm. or 60 grains. 
Potassii et Sodii Tartras. — Potassium and Sodium Tartrate, U. S. P. 

Dosage : 8 gm. or 120 grains. 
Pulvis Effervescens Compositus. — Seidlitz Powder, U. S. P. Dosage : 

One set of two papers. 
Potassii Hydroxidum. — Potassium Hydroxide, U. S. P. 
Liquor Potassii Hydroxidi. — Solution of Potassium Hydroxide, U. S. P. 

Dosage : 1 c.c. or 15 minims. 
Potassii lodidum. — Potassium Iodide, U. S. P. Dosage: 0.3 to 2 gm. 

or 5 to 30 grains. 
Potassii Permanganas. — Potassium Permanganate, U. S. P. Dosage : 0.03 

to 0.06 gm. or y 2 to 1 grain. 
Procain. — Procain, N. N. R. For local anesthesia. 
Protargol — Protargol, N. N. R., Silver Proteinate. Dosage : 1.2,000 to 

1 per cent solutions. 
Prunus Virginiana. — Wild Cherry, U. S. P. 
Syrupus Pruni Virginianae. — Syrup of Wild Cherry, U. S. P. Dosage : 

5 c.c. or 1 fluidram. 
Quinina. — Quinine, U. S. P. Dosage: 0.25 gm. or 4 grains 
Quininae Bisulphas. — Quinine Bisulphate, U. S. P. Dosage : 0.25 gm. or 

4 grains. 
Quininae Hydrochloridum. — Quinine Hydrochloride, U. S. P. Dosage: 

0.25 or 4 grains. 
Quininae Sulphas. — Quinine Sulphate, U. S. P. Dosage: 0.25 or 4 

grains. 
Quininae Tannas.— Quinine Tannate, N. N. R. Dosage: 0.5 gm. or 7y 2 

grains. 
Quininae et Ureae Hydrochloridum. — Quinine and Urea Hydrochloride, 

N. N. R. Dosage : 0.25 gm. or 4 grains. 
Resorcinol. — Resorcinol, U. S. P. Dosage : 0.125 gm. or 2 grains. 
Rheum. — Rhubarb, U. S. P. Dosage: 1 gm. or 15 grains. 
Extractum Rhei. — Extract of Rhubarb, U. S. P. Dosage: 0.25 gm. or 

4 grains. 
Tinctura Rhei Aromatica. — Aromatic Tincture of Rhubarb, U. S. P. 

Dosage : 2 c.c. or 30 minims. 
Syrupus Rhei Aromaticus. — Aromatic Syrup of Rhubarb, U. S. P. 

Dosage : 8 c.c. or 2 fluidrams. 



58 USEFUL DRUGS 

Rosa. — Rose. 

Aqua Rosae. — Rose Water, U. S. P. 
Saccharum. — Sugar, U. S. P. 
Syrupus. — Syrup, U. S. P. 
Saccharum Lactis. — Sugar of Milk, II. S. P. 
Salvarsan. — See Arsphenamine. 

Santonin urn. — Santonin, U. S. P. Dosage-: 0.065 gm. or 1 grain. 
Sapo.— Soap, U. S. P. 

Linimentum Saponis. — Soap Liniment, U. S. P. 
Sapo Mollis. — Soft Soap, U. S. P. 

Scilla. — Squill, II. S. P. Dosage: 0.125 gm. or 2 grains. 
Tinctura Scillae. — Tincture of Squill, U. S. P. Dosage : 1 c.c. or 15 

minims. 
Syrupus Scillae. — Syrup of Squill, U. S. P. Dosage : 2 c.c. or 30 
minims. 
Scopolaminae Hydrobromidum. — Scopolamine Hydrobromide, U. S. P. 

Dosage : 0.5 mg. or 1/125 grain. 
Senna. — Senna, U. S. P. Dosage : 4 gm. or 60 grains. 

Fluidextractum Sennae. — Fluidextract of Senna, U. S. P. Dosage: 2 

c.c. or 30 minims. 
Syrupus Sennae. — Syrup of Senna, U. S. P. Dosage: 4 c.c. or 1 
fluidram. 
Serum Antidiphthericum. — Antidiphtheric Serum, Diphtheria Antitoxin, 
U. S. P. Dosage: Immunizing, 500 to 1,000 units; curative, 10,000 
units. • 

Serum Antidiphthericum Purificatum. — Purified Antidiphtheria Serum, 

U. S. P. 
Serum Antidiphthericum Siccum. — Dried Antidiphtheria Serum, II. S. P. 
Serum Antimeningococcicum. — Antimeningococcus Serum. Dosage: 5 c.c. 

to 30 c.c. 
Serum Antitetanicum. — Antitetanic Serum, U. S. P. Dosage : Immuniz- 
ing, 1,500 units; in tetanus, 3,000 to 20,000 units. 
Serum Antitetanicum Purificatum. — Purified Antitetanic Serum, U. S. P. 
Serum Antitetanicum Siccum. — Dried Antitetanic Serum, U. S. P. 
S i n a p i s . — Mustard. 
Sinapis Nigra. — Black Mustard, II. S. P. Dosage : 8 gm. or 120 grains. 
Emplastrum Sinapis. — Mustard Plaster, U. S. P. 

Oleum Sinapis Volatile. — Volatile Oil of Mustard, U. S. P. Dosage : 
0.008 c.c. or y 2 minim. 
Sodii Arsanilas. — Sodium Arsanilate, N. N. R. Dosage: 0.02 gm. or 1/3 

grain. 
Sodii Arsenas. — Sodium Arsenate, U. S. P. Dosage : 5 mg. or 1/10 grain. 
Sodii Benzoas. — Sodium Benzoate, II. S. P. Dosage : 1 gm. or 15 grains. 
Sodii Bicarbonas. — Sodium Bicarbonate, II. S. P. Dosage : 1 gm. or 15 

grains. 
Sodii Biphosphas. — Sodium Aci,d Phosphate, N. N. R. (to be added). 

Dosage: 1 to 1.5 gm. or 15 to 20 grains. 
Sodii Boras. — Sodium Borate, II. S. P. Dosage: 0.5 gm. or iy 2 grains. 
Sodii Bromidum. — Sodium Bromide, II. S. P. Dosage : 1 gm. or 15 grains. 
Sodii Cacodylas. — Sodium Cacodylate, N. N. R. Dosage: 0.03 gm. or % 

grain. 
Sodii Carbonas Monohydratus. — Monohydrated Sodium Carbonate, U. S. 

P. Dosage : 0.25 gm. or 4 grains. 
Sodii Chloridum. — Sodium Chloride, II. S. P. Dosage : 16 gm. or 240 

grains, emetic ; 4 gm. or 60 grains, laxative. 
Sodii Hydroxidum.— Sodium Hydroxide, U. S. P. 

Liquor Sodii Hydroxidi.— Solution of Sodium Hydroxide, U. S. P. 
Dosage: 1 c.c. or 15 minims. 
Sodii lodidum. — Sodium Iodide, II. S. P. Dosage : : 0.5 gm. or iy 2 grains. 
Sodii Nitris.— Sodium Nitrate, U. S. P. Dosage: 0.065 or 1 grain. 



USEFUL DRUGS 



59 



Sodii Phosphas. — Sodium Phosphate, U. S. P. Dosage: 2 gm. or 30 

grains. 
Sodii Phosphas Effervescens. — Effervescent Sodium Phosphate, U. S. P. 

Dosage : 8 gm. or 120 grains. 
Sodii Salicylas. — Sodium Salicylate, U. S. P. Dosage : 1 gm. or 15 grains. 
Sodii Sulphas. — Sodium Sulphate, U. S. P. Dosage : 16 gm. or 240 grains. 
Sodii Sulphis. — Sodium Sulphite, U. S .P. Dosage : Applications of 1 

in 10 or 1 dram to the ounce. 
Sodii Thiosulphas. — Sodium Thiosulphate, U. S. P. Dosage : 1 gm. or 15 

grains. 
Staphylococcus Vaccine. — See Vaccine, Staphylococcus. 
Stramonium. — Stramonium, U. S. P. 
Strophanthinum. — Strophanthin, U. S. P. Dosage: 0.0003 gm. or 1/200. 

grain. 
Strophanthus. — Strophantus, U. S. P. 

Tinctura Strophanthi. — Tincture of Strophanthus, U. S. P. Dosage: 

0.5 c.c. or 8 minims. 
Strychnina.— Strichnine, U. S. P. Dosage: 0.0005 to 0.005 or 1/100 

to 1/10 grain. 
Strychninae Nitras. — Strychnine Nitrate, U. S. P. Dosage: 0.001 gm. 

or 1/60 grain. 
Strychninae Sulphas. — Strychnine Sulphate, U. S. P. Dosage: 0.001 

gm. or 1/60 grain. 
Suiphonal. — See under Sulphonmethanum. 
Sulphonethylmethanum. — Sulphonethylmethane, U. S. P. — Trional. 

Dosage : 1 gm. or 15 grains. 
Sulphonmethanum. — Sulphonmethane ,U. S. P. — Suiphonal. Dosage: 1 

gm. or 15 grains. 
Sulphur. — Sulphur. 

Sulphur Lotum. — Washed Sulphur, U. S. P. Dosage: 4 gm. or 60 

grains. 
Sulphur Praecipitatum. — Precipitated Sulphur, U. S. P. Dosage: 4 gm. 

or 60 grains. 
Sulphur Sublimatum. — Sublimed Sulphur, U. S. P. Dosage: 4 gm. 

or 60 grains. 
Unguentum Sulphuris. — Sulphur Ointment, U. S. P. 
Tannalbin. — See under Acidum Tannicum. 
Terebinthina. — Turpentine, U. S. P. 
Oleum Terebinth in ae. — Oil of Turpentine, U. S. P. Dosage: 1 c.c. or 

15 minims. 
Terpini Hydras. — Terpin Hydrate, U. S. P. Dosage: 0.125 gm. or 2 

grains. 
Tetanus Antitoxin. — See Serum Antitetanicum. 
Theobromitas Oleum. — Oil of Theohroma, U. S. P. 
Theobromina. — Theobromine, N. N. R. Dosage : 0.3 gm. or 5 grains. 
Theobrominae Sodio-Salicylas. — Theobromine Sodium Salicylate, N. N. 

R. — Diuretin. Dosage: 0.5 gm. or TV 2 grains. 
Thymol. — Thymol, U. S. P. Dosage: 0.1 gm. or 2 grains. 
Thymolis lodidum. — Thymol Iodide, U. S. P. 
Thyrordeum Siccum. — Dried Thyroids, U. S. P. Dosage : 0.06 gm. or 1 

grain. 
Typhoid Vaccine. — See Vaccine. Typhoid. 

Tiglii Oleum. — Croton Oil, TJ. S. P. Dosage : 0.05 c.c. or 1 minim. 
Tragacantha. — Tragacanth, U. S. P. 
Trinitrophenol. — Trinitrophenol, U. S. P. Dosage: 0.03 gm. or y 2 

grain. 
TrionaJ. — See under Sulphonethylmethanum. 
Tuberculin urn.— Tuberculin, N. N. R. 
Urotropin. — See Hexamethylenamina. 
Vaccine, Staphylococcus. — Staphylococcus Vaccine, N. N. R. (to be 

added). Dosage: 1.000,000,000 bacteria. 
Vaccine, Typhoid. — Typhoid Vaccine, N. N. R. Dosage : 500.000,000 to 

1,000,000,000 bacteria. 



60 USEFUL DRUGS 

Vaccine, Virus. — See under Virus, Vaccine. 
Valeriana. — Valerian, U. S. P. 

Tinctura Valerianae Ammoniata. — Ammoniated Tincture of Valerian, 
U. S. P. Dosage: 2 c.c. or 30 minims. 
Veronal. — N. N. R. Dosage: 0.3 to 0.6 gm. or 5 to 10 grains. 
Sodii Diaethyl-Barbituras. — Sodium Diethyl-Barbiturate, N. N. R. 

Dosage : 0.3 to 0.6 gm. or 5 to 10 grains. 
Virus Vaccinum. — Vaccine Virus, N. N. R. 

Zinci Acetas. — Zinc Acetate, U. S. P. Dosage: 0.125 gm. or 2 grains. 
Zinci Chloridum. — Zinc Chloride, U. S. P. 

Liquor Zinci Chloridi.— Solution of Zinc Chloride, U. S. P. 
Zinci Oxidum. — Zinc Oxide, U. S. P. Dosage : 0.25 gm. or 4 grains. 

Unguentum Zinci Oxidi. — Ointment of Zinc Oxide. 
Zinci Stearas. — Zinc Stearate, U. S. P. 

Zinci Sulphas. — Zinc Sulphate, U. S. P. Dosage: 2 gm. or 30 grains. 
Zingiber. — Ginger, U. S. P. Dosage : 1 gm. or 15 grains. 

Tinctura Zingiberis. — Tincture of Ginger, U. S. P. Dosage : 2 i.e. or 
30 minims. 



SOME THERAPEUTIC PRINCIPLES 



INDIVIDUAL TENDENCIES 

Teachers of therapeutics emphasize the necessity of 
individualizing the patient but sometimes forget the 
importance of family tendencies. There is no more 
doubt that a person inherits family weakness and 
family strength or, if the phrase is preferred, family 
tendencies, than there is that he inherits the features 
and general physique of his parents and grandparents. 
These tendencies are often recognizable by the general 
appearance and physical findings, but if not, they can 
almost always be discovered by a careful investigation 
into the family history of the patient. 

THE FAMILY HISTORY 

It should be the rule of the physician to inquire into 
the family history carefully with every new patient. 
Heredity and environment are the two factors most 
prominent in the production of physical and mental 
health. Environment may improve or mar heredity, but 
cannot change it. Heredity is therefore the most impor- 
tant factor in raising and developing an ideal race. 
The importance of good environment for the perpet- 
uation of physical and mental health requires no dis- 
cussion. But environment will not eliminate a heredi- 
tary tendency to disease or to mental or physical insuf- 
ficiency. Neither will environment develop perfect 
mental and physical health when there is an inherited 
deficiency, although environment can markedly im- 
prove deficiency caused by injury or acquired by 
disease. 

The environment of prospective fathers and 
mothers and their future children is being constantly 
improved by the public health advances now being 
made in all communities but, as has been stated, this 
will not prevent the ravages of inherited disease 
(syphilis, epilepsy, insanity, imbecility, physical weak- 
ness) any more than environment can produce twins, 
beauty, geniuses or permanent health. In fact, 



62 THE SCOPE OF THERAPEUTICS 

improved environment is doing more for the defec- 
tives in all lines than for those of good heredity, who 
would survive a less improved environment. 

UNSCIENTIFIC PRESCRIBING 

Lack of scientific therapeutic teaching causes some 
physicians to use secret proprietary preparations for 
various conditions, when, in most cases, the active 
ingredient of the preparation used is a drug which 
they have long used, but in a simpler and less expen- 
sive manner. The general practitioner who writes of 
his therapeutic successes should constantly bear in 
mind, first, the trend of troublesome conditions to 
recovery; second, that it is not always the last drug, 
preparation or treatment that benefited the patient, 
but that the previous treatment may really have 
caused the cure; third, that many a new drug or new 
preparation offered with the enthusiasm of the physi- 
cian cures a. patient by psychic effect, much as does a 
change of physicians or a change of environment in 
many cases. 

THERAPEUTICS MORE THAN MEDICINE 

The scope of therapeutics and its relation to the 
practice of medicine are well shown by the accom- 
panying chart prepared by Dr. Osborne. (Amer. 
Jour. Med. Sri., 1916.) 

A disease cannot be correctly treated unless the fol- 
lowing facts are considered : 

1. Can the etiologic factor in a given disease be dis- 
covered, and can it be removed ? This is the primary 
treatment. 

2. What physiologic processes in this patient are 
disturbed by this disease? The aim of all treatment 
should be the attempt to correct such disturbed physi- 
ology, and at the same time not disturb the normal 
physiologic processes. 

3. The pathologic conditions which are the result of 
the disease should be removed if possible, ameliora- 
ted if removal is not possible, and never irritated or 
made worse by any medicinal or physical treatment. 



THE SCOPE OF THERAPEUTICS 



63 



Special care should be taken that whatever treatment 
is deemed advisable for the patient, it should not aggra- 
vate or make worse the pathologic condition present. 




4. The symptoms and signs of the disease which in 
their totality determine the diagnosis, and the extent to 
which the pathology of the disease has progressed, are 
in their totality of minor and secondary importance in 



64 PAIN AS A SYMPTOM 

the treatment. On the other hand, individual trouble- 
some symptoms must be removed or ameliorated, else 
normal physiologic processes which are necessary to 
recovery cannot be performed, and toxemias that 
otherwise need not have occurred may perhaps be the 
determining cause of the nonrecovery of the patient. 

PAIN AS A SYMPTOM 

Of all symptoms, pain is most important; it is one 
from which the patient must have relief. It does not 
seem to make much difference whether such pain is 
pathologically excusable or present only on account of 
psychologic mistake, the nervous irritability and 
depression caused by it must be taken into consider- 
ation and must be treated or, better, managed. At 
least, pain must be prevented at any cost. This does 
not mean that the physician should hasten to the use 
of unneeded narcotics, nor that he should ever use a 
narcotic without regret and without the extra super- 
vision that should always go with such treatment, but 
it is the skillful, thoughtful, discriminating physician 
who can determine the best method of eradicating the 
symptom of pain -in each individual patient. It is 
frequently possible, in making examinations or in 
treating patients, to secure for them great comfort 
merely by altering the posture. Pain after operation 
is frequently due to lack of support of the back. Inci- 
dentally the soothing effects of the warm bath or the 
warm pack should not be overlooked. It is frequently 
possible by the use of such means to relieve pain with- 
out the employment of a narcotic. 



INFECTIOUS DISEASES 



SCARLET FEVER 
PROPHYLAXIS OF SCARLET FEVER 

"Scarlatina," "scarlet rash" and "scarlet fever" are 
synonymous terms. While scarlet fever may be, and 
often is, a very serious disease, with high tempera- 
ture, severe sore throat, intense and widely spread 
eruption, followed by copious desquamation, on the 
other hand the fever may be slight or entirely absent, 
the throat may not show more than slight congestion, 
the eruption, if not entirely absent, may be not very 
pronounced in appearance, not widely spread over the 
body and of rather transient duration, while the 
desquamation may be so slight as to be hardly 
recognizable. 

It is now generally recognized not only that the very 
mild cases may be followed by the most serious 
sequelae which are observed after the severe forms of 
the disease, and particularly by inflammation of the 
kidneys, but also that severe forms of scarlet fever 
may be, and often are, contracted from patients whose 
symptoms have been exceedingly mild. 

A possible explanation of apparent immunity to 
scarlet fever may be, at least in some cases, that these 
immune individuals have in their earlier life passed 
through an attack of scarlet fever of so mild a type 
that a physician was not called to the patient, or if one 
was called, he did not recognize the nature of the dis- 
ease. This, however, probably does not explain all 
cases of apparent immunity. Undoubtedly there are 
many persons who never contract the disease except 
after unusual exposure. On the other hand, it is 
unjustifiable carelessly or wittingly to expose a child 
or adult to the disease, no matter how mild the type 
may be. 

CONTAGIOUSNESS 

It was long believed that the contagious element of 
the disease existed in the scales which occur in greater 
or less profusion during desquamation. At present 



66 SCARLET FEVER 

we believe that the scales in themselves do not possess 
the power of transmitting the disease. On the other 
hand, they may become contaminated by infected 
secretions; hence it is important to prevent the dis- 
semination of these scales. 

The belief has been gaining ground that the element 
of contagion exists actively and abundantly in the 
secretions from the throat and nose, and also in the 
discharges from the ear and from the suppurating 
glands, when they are present. Also it is believed that 
when the disease is transmitted by dissemination of the 
scales, it is due to the fact that the latter have been 
contaminated by these secretions. Obviously then, the 
problem which confronts both family and physician, 
as well as sanitarian, is to control the dissemination of 
these various secretions, discharges and exfoliations. 

ISOLATION AND DISINFECTION 

The mastery of the problem embraces first, isola- 
tion; second, disinfection. 

The establishment of isolation often taxes severely 
the tact and good judgment of the physician. If the 
family is large and lives in a small house or apartment 
and on a limited income, and if the- municipality pos- 
sesses an isolation hospital, or wards of a hospital are 
set apart for the treatment of contagious diseases, the 
easiest way is to transport the patient immediately to 
such an institution. Here he will be under the care 
of attendants who are accustomed to handle patients 
with the disease, and who are trained to exercise all 
the precautions necessary to prevent the spread of the 
disease. Most towns have no special provision for 
taking care of scarlet fever, and in such cases the 
patients must be treated in their own homes. If the 
family has ample means and lives in a large house, a 
large room or a suite of rooms must be set apart for 
the exclusive use of the patient and the special atten- 
dant, who must be secured to give him exclusive atten- 
tion. Such an apartment or suite should, if possible, 
be selected on the top floor of the house or at the 
end of a hall, so that the other members of the family 
will have no occasion to go near it. The room should 



ISOLATION IN SCARLET FEVER 67 

be large and sunny, and all unnecessary articles, such 
as curtains, upholstered furniture, and ornaments, 
should be removed, so that there will be as few articles 
as possible to which the disease poison may adhere 
and which will need to be cleaned or destroyed after 
the recovery of the patient. The attendant should not 
invade other parts of the house. Food and other 
necessities should be left outside the door of the apart- 
ment occupied by the patient by another member of 
the household. Similarly, everything which requires 
removal from the infected apartment should be dis- 
infected and placed outside the apartment, and thence 
carried away. The most important things which are 
likely to require removal are dishes, clothing, and 
excreta. These should be disinfected by being placed 
in suitable vessels and then allowed to soak for an 
hour in a 2.5 per cent, solution of phenol (carbolic 
acid). Things which are of little or no value and 
which are combustible, such as the remnants of food 
and pieces of cloth or paper which have been used 
about the room, should be burned. If the nurse finds 
it necessary to leave the patient's quarters, she should 
change all her outer garments outside of the patient's 
room, she should cover her hair, and avoid coming 
into close contact with anyone. These precautions of 
isolation should be carried out continuously and 
strictly until desquamation is entirely completed. 
During the period of desquamation the patient should 
be sponged or bathed once or twice a day with hot 
water (and if there are bathroom facilities the con- 
valescent should have a daily hot tub bath), and then 
the skin should be anointed with adeps lanse hydrosus 
(lanolin) which has been softened with almond (or 
other bland) oil, and perfumed to suit. Phenol (car- 
bolic acid) ointments are inadvisable, as any absorp- 
tion would irritate the kidneys. Sponging with alcohol 
is contra-indicated. After desquamation has ceased, 
the patient should remove all the clothing which he 
has been wearing, take a warm bath, with soap, and 
have his head well shampooed. Then he must dress 
throughout in fresh clothing. 



68 SCARLET FEVER 



TERMINAL DISINFECTION 



The apartment should be thoroughly disinfected. 

Fumigation after scarlet fever, diphtheria and 
measles does not seem to pay for the cost and trouble 
it causes. Proper fumigation with strong formal- 
dehyd, carried out by boards of health, should still be 
done for smallpox and tuberculosis, and perhaps for 
erysipelas, childbed fever and tetanus, especially in 
hospitals. Spraying with germicides of all the imme- 
diate surroundings of an infected patient is the 
method of disinfection now most satisfactory. All 
washable clothing and bedclothing should be boiled; 
all other clothing should be baked and put into the 
sunlight. Carpets and rugs may be thoroughly sunned 
and aired or washed with antiseptics. Various wash- 
ing solutions may be used, such as chlorinated lime 
solutions, 5 per cent., formaldehyd solutions, corrosive 
sublimate solutions 1 : 500, 5 per cent, phenol (car- 
bolic acid) solutions, or better, the higher coal-tar 
disinfectants, as liquor cresolis compositus. The New 
York Board of Health orders the woodwork and floors 
scrubbed with hot solution of 1 pound of washing soda 
to 3 gallons of hot water. Bedding and night clothing 
are ordered soaked in phenol solutions and then boiled 
in soapsuds for half an hour. Books and toys should 
be burned. It should never be forgotten that outside 
air and sunlight are among the most useful of disin- 
fectants. 

ISOLATION OF PATIENT 

When it is possible to carry out such strict isolation 
as has been described, there is no necessity of quaran- 
tining the rest of the family but, unfortunately, such 
complete isolation is ideal and can rarely be carried 
out in actual practice. Even when a large family 
occupies a few rooms, it is essential that one room be 
selected for the patient, and that he be kept in it con- 
stantly, and that the other members of the family be 
kept out of it entirely, except that one who is selected 
to act as the attendant, usually the mother. Under such 
conditions it is usually entirely impracticable for the 
attendant to remain constantly in the room with the 
patient. She must frequently leave-the room, not only 



PROPHYLAXIS OF SCARLET FEVER 69 

to get things which the patient requires, but also to 
perform services for the remainder of the family. 
Under these circumstances it is desirable and often 
entirely practicable that such members of the family 
as attend school, or work in stores or shops, should 
leave home, and live elsewhere for six or eight 
weeks. Those who are obliged to remain at home 
should avoid as much as possible coming in contact 
with the attendant. The latter should have several 
aprons, with sleeves, and large enough to cover all her 
outer clothing. One of these she should wear con- 
stantly while in the patient's room. Needless to state, 
she should always wash her hands on leaving the 
room. 

PROPHYLACTIC MEASURES OF PHYSICIANS 

It is generally believed by the medical profession 
that physicians who use even a moderate degree of 
caution rarely transport the disease from a patient 
to another individual, and when this does happen, the 
victim is usually a member of his own family. He 
should endeavor to so arrange his calls that he will not 
go directly from a patient ill with scarlet fever to a 
family in which there is a child. On entering the room 
of such a patient he should put on a long cotton, linen 
or rubber coat. He should avoid sitting on the bed, or 
allowing the bedclothing to come in contact with his 
own clothing. On leaving the room he should thor- 
oughly wash his hands and dry them on a clean towel 
and remove the gown just outside the patient's door. 

PROPHYLAXIS DURING CONVALESCENCE 

During convalescence the patient should not be 
allowed to use books from the public library or the 
public school, and should use only such books, maga- 
zines and newspapers as can be burned when he is 
through with them, or when the period of isolation is 
ended. Neither should he be allowed to write and 
send letters through the mail or by messenger to his 
friends. 

No drug treatment is known that will prevent per- 
sons exposed to the disease from contracting it or 
developing it. Al-though belladonna has been exten- 



70 SCARLET FEVER 

sively used for this purpose, there is no reason for 
believing that it has ever produced this result. 

Although often advocated, and sometimes used, the 
impregnation of the atmosphere of the room with anti- 
septics (phenol) and aromatic oils seems to be of no 
value in killing the germs or in hastening recovery. 
Various cresol preparations and oil of eucalyptus have 
been especially recommended for this purpose, but 
their value is small, and the danger of too much 
absorption of phenol vapor causing kidney irritation 
is ever present. 

Dogs and cats must be excluded from all patients 
suffering with contagious diseases, and this is espe- 
cially true of scarlet fever. The doors and windows 
must be screened from flies, if it is the season for 
them. . 

VACCINES IN PROPHYLAXIS 

The use of vaccines of streptococci and other organ- 
isms found in the throat during scarlet fever has been 
suggested as desirable in prophylaxis. The use of 
extracts of the scales and of convalescent serum has 
also been suggested. The available evidence seems to 
indicate that convalescent serum may have virtue both 
in prophylaxis and treatment. There is as yet no good 
reliable evidence to justify the use of the other meas- 
ures mentioned. 

TREATMENT 

A. Isolation. — Strict isolation measures, already dis- 
cussed under other headings, are most important in 
this disease, and the nurse should distinctly under- 
stand that it is the secretions of the mouth and nose, 
and perhaps suppurating complications, that carry 
infection. The greatest possible care to disinfect or 
sterilize articles contaminated by such secretions 
should be exercised, as the infecting germ is persistent 
and lives for a long time unless killed. The most 
efficient cleanliness of the patient, nurse, and the physi- 
cian who handles the case is also essential. 

B. Diet. — As in the beginning of all diseases, espe- 
cially the infectious diseases, the bowels should be 
thoroughly evacuated with castor-oil, calomel, or what- 
ever the physician deems best; subsequently, they 



TREATMENT OF SCARLET FEVER 71 

should be moved daily by some gentle laxative. If 
the patient has diarrhea, it is generally caused by a 
mistake in the diet. Milk is the best basis for the diet 
in scarlet fever. Intestinal indigestion is not frequent. 
Foods that add products to the blood that during 
excretion are likely to cause irritation of inflamed kid- 
neys should be avoided. The aim of the physician 
should be to diminish the inflammation and irritation 
of the skin, to keep it warm, to attempt to keep it 
moist and promote its secretion, and to give a diet 
rather low in proteins and without meat, meat extrac- 
tives or purins. Also, if possible, no drugs should be 
administered that tend to irritate the kidneys, espe- 
cially after the first week of the illness. Such drugs 
are coal-tar products, synthetic products, cafleins, and 
any of the drugs that are known as stimulant diuretics. 
Even drugs that contain salicylic acid should be 
avoided. 

The greater the intensity of the disease, the more 
liquid the diet should be. While milk is the basis, 
thin cereal gruels are advisable from the start. Malted 
milk may be added to this diet, and lemonade or 
orangeade or oranges, as deemed advisable. Later, 
toasted bread, crackers, and various kinds of cereals, 
and still later, baked potato, rice, corn starch, and 
many other cereal and milk foods, as well as a greater 
variety of fruit, should constitute the diet. 

As soon as the convalescence is established, and 
even before, if the disease is prolonged, a small dose 
of iron should be given daily, as on the above diet 
the blood cannot get this nutriment. A sugar of iron 
(saccharated oxid of iron) 3-grain tablet should be 
given from one to three times a day. Sodium chlorid 
should always be given a patient from the beginning, 
once or twice a day, in one or more of the feedings. 
If there is a tendency of the nose and throat to bleed, 
or there are hemorrhages in any other part of the 
body, lime-water should be added to the diet. The 
patient should always receive plenty of water. If 
any apparent irritation of the kidneys occurs, it may 
be well to withhold the fruits and to temporarily 
diminish the amount of food. 



72 SCARLET FEVER 

C. Fever. — If the temperature becomes very high it 
may be advisable to give several doses of an antipy- 
retic, such as acetanilid, antipyrin, or acetphenetidin, 
always bearing in mind the irritant effect of these 
drugs on the kidneys. Warm sponging of the body 
will also tend to reduce the temperature and make the 
patient comfortable. It relieves itching, and many 
times is soothing. Cold sponging in scarlet fever is 
inadvisable. If the fever is excessive, tepid sponging 
may be tried. Restlessness and sleeplessness will also 
increase the fever, and often a few doses of sodium 
bromid will be of great benefit. It not only causes 
the patient to sleep, but reduces the irritability of the 
peripheral nerves. Also, anything that relieves itching 
or burning of the skin will reduce the temperature and 
the irritability. Quinin is inadvisable, as it is excitant 
to the brain and may tend to congest the ears and add 
one more element that may cause middle-ear compli- 
cations. An ice cap to the head, unless actual menin- 
gitis is present and the hair is clipped close to the 
scalp, is inadvisable. Whether ice caps to the head 
ever reduce general temperature is open to grave doubt. 
If there is meningitis, they may relieve the local con- 
gestion. Ice caps, however, tend to fall to one side or 
the other of the head and unnecessarily chill the ears, 
and may become another factor in causing middle- 
ear inflammation. The value of an ice bag over the 
mastoid when it is in danger is not under discussion; 
but an ice cap over an external ear is not called for, 
and may do harm. 

D. Care of the Nose. — Antiseptic, alkaline and 
cleansing gargles and sprays for the throat should be 
freely used. The cleaner the nose and throat in scarlet 
fever, the less the secondary infection, the less the 
toxemia, and the less the danger. Whatever method 
is used to clean the nostrils, such pressure of the liquid 
as would tend to force infection into one or. the other 
of the sinuses must never occur. If there is no puru- 
lent discharge from the nostrils, it is inadvisable to 
spray or douche them, as much harm can be done from 
too strenuous or unnecessary treatment of the nose. 

E. Skin. — Whatever the temperature, hot sponging 
for cleanliness once or twice a day is soothing and 



THE HEART IN SCARLET FEVER 73 

advisable. Sponging with alcohol in any form is inad- 
visable. Alcohol, unless the solution is so dilute as to 
represent not alcohol but only an alcoholic odor, will 
tend to dry the skin, cause more itching, and more dis- 
comfort. Sponging with bicarbonate of soda in warm 
water soothes the irritability and stops the itching. 
Powdering with some soothing talcum powder also 
stops itching and quiets the patient. 

As soon as the acute eruption is over and desquama- 
tion is about to begin, gentle rubbing into the skin 
of some bland oil, as cocoanut oil or almond oil or 
wool-fat, sometimes with a little glycerin and water, 
hastens the removal of the dried epithelium, prevents 
the scales from flying about (although these scales do 
not carry the contagium) and is very quieting to the 
patient, by preventing the irritation and itching. As 
soon as convalescence is established, a more active 
massage of the skin and muscles is advisable. 

The use of mercuric chlorid or phenol solutions of 
any strength, or phenol ointments, on the skin, is 
inadvisable. Most of these solutions tend to dry the 
skin still more ; and the use of phenol ointment might 
result in some absorption and therefore is of danger 
to the kidneys. Also, as it seems to be a fact that 
contagium is not spread by the skin, there is no excuse 
for germicidal ointments or applications. 

Unless the temperature is very high and head symp- 
toms are present, it is unnecessary to cut the hair 
close to the scalp. If the scalp itches, as it often does, 
a little petrolatum may be rubbed into it and will 
give relief. A tar soap may stop the itching. Oil 
of eucalyptus has been recommended and used as a 
non-irritant application to the skin and scalp. Also, 
throats have been swabbed with oil of eucalyptus prep- 
arations, in the belief that eucalyptus oil is especially 
antiseptic in throat contagions. 

F. The Heart. — Cardiac stimulation, especially in 
children, is rarely needed in this disease. The toxin 
of scarlet fever is not as depressant as is that of diph- 
theria, and strychnin is generally inadvisable as it 
causes too much cerebral stimulation, especialy in 
children. 



74 SCARLET FEVER 

If a long septic process follows scarlet fever, or 
there is later a septicemia, small doses of strychnin 
may be of value, and alcohol is of value as not only 
adding a food, but as tending to prevent a dangerous 
acidemia. Also, in such septic conditions, as much 
carbohydrates should be given as the patient can 
dieest. 

If joint complications occur, there is likely to be an 
endocarditis, and perhaps chorea may develop. 

G. Late Complications. — Middle-ear inflammations 
should be expected and watched for. The drums 
should be early punctured if there is pressure, and the 
services of an expert on diseases of the nose, throat 
and ears should be early sought by the physician, if 
such complications occur. 

The glands of the neck are almost always congested 
and enlarged in scarlet fever, and one or more may 
tend to suppurate. It often seems that the local appli- 
cation of a proper-sized ice-bag to a gland, if the 
patient will tolerate such an application, aborts serious 
inflammation. However, if such a suspicious gland 
continues to enlarge, the temperature rises and blood 
counts show an increasing leukocytosis, there is prob- 
ably pus formation, and the abscess should be soon 
opened. The surgeon, however, often decides that he 
prefers to have warm applications for a short time to 
cause more rapid breaking down of the central suppu- 
rating portion of the gland, so that more complete 
evacuation may occur on incision. The subsequent 
dressings and treatment of such an abscess are purely 
surgical. The temperature will generally drop after 
the evacuation of the pus, unless there is some other 
localized septic process. 

Although the percentage of occurrence of nephritis 
in or following scarlet fever is not great, it occurs 
sufficiently often to be always looked for and expected. 
As above urged, all drugs that irritate the kidneys 
and all foods that cause irritation should be withheld. 
While it has not been shown that meat will cause 
nephritis, it is not necessary to add meat to the diet 
in scarlet fever. Many believe that eggs should not 
be allowed. The withholding of eggs as a preventive 
of nephritis hardly seems necessary. Some physicians 
even withhold salt from the food ; this does not seem 



CONVALESCENCE IN SCARLET FEVER 75 

necessary. In giving fluids, patients may be encour- 
aged to take larger quantities by supplementing water 
with citrate solutions or lemonade. This not only aids 
diuresis but may also be of value in reducing acidosis. 
If the amount of urine greatly diminishes and albumin 
appears, there may not be an actual nephritis, but it 
may be well to attempt to forestall or abort such an 
inflammation. Hot packs or applications to the lumbar 
region can do nothing but good. Perhaps the best 
preventive of nephritis is prolonged rest in bed for 
at least a week after the fever has ceased, as it seems 
to be a fact that the better the action of the skin, the 
less likely are the kidneys to become inflamed, and the 
skin will be warmer, and is likely to be more moist in 
bed than when the patient is about. Chilling of the 
body following scarlet fever is an important added 
cause for the development of nephritis. Also, if the 
kidneys have been sufficiently irritated to cause a dis- 
tinct predisposition to nephritis, an increased use of the 
muscles, whether by playing, exercise, or work, too 
soon after the acute symptoms are over, may so 
increase the excretory substances from muscle metab- 
olism as to add a very tangible factor to further irri- 
tation of the kidneys and consequent nephritis. If 
nephritis develops, the treatment should be as described 
under that heading. 

H. Convalescence. — As just suggested, the patient 
should remain in bed one week after the fever has 
ceased, and the subsequent convalescence should be 
prolonged and carefully watched. During the acute 
stage of the disease the urine should be examined 
daily, to note the first appearance of albumin and how 
long it persists. During the convalescence the urine 
should be examined at least every other day for two 
weeks, and once or twice a week for several weeks 
more. The diet should be increased and most foods 
allowed, except that it may be well for at least two 
weeks not to give meat. During this period the 
patient should continue to receive iron. If the weather 
is cold and damp, great care must be taken that the 
patient be not exposed. 

Just how long the germ of infection persists in the 
mouth, and especially in the nose, has not been deter- 
mined, but secondary cases can occur when the patient, 



76 SCARLET FEVER 

especially if he has a nasal discharge, has been allowed 
to play with other susceptible children. It was long 
thought that the desquamating skin was the cause of 
this late infection of others. 

/. Use of Vaccines. — As it is conceded that strepto- 
coccic infection is concomitant with the cause of many 
of the complications of scarlet fever, vaccine treat- 
ment with stock vaccines or autogenous vaccines has 
been suggested and advised to hasten the eradication 
of left-over septic processes. The same rules and 
regulations, and the same frequency of success will 
doubtless occur in the septic processes following scar- 
let fever as with any other septic process. 

Convalescent Serum. — The most recent and certainly 
a scientific treatment for scarlet fever is the injection 
of convalescent blood or serum. Reiss and Hertz 
(Miinchen. med. Wchnschr., Aug. 31, 1915) used the 
mixed serum from several scarlet fever convalescents. 
They injected it intravenously in large doses, 50 c.c. 
for children and 100 c.c. for adults. The results, they 
believe, were lifesaving in many instances. The injec- 
tions were commenced on the fourth or fifth day, and 
continued as long as needed. The serum was taken 
from donors in the eighteenth to twenty-fourth day 
of convalescence, after negative Wassermann tests and 
the exclusion of tuberculosis and sepsis. 

Zingher employed convalescent whole blood, aspirat- 
ing it from the cephalic vein of the donor, citrating it 
by adding the blood to a 10 per cent solution of sodium 
citrate in the proportion of 1 ounce of blood to each 
cubic centimeter of the citrate solution. The needle 
is not removed from the donor's vein until sufficient 
blood (from 4 to 10 ounces) has been secured. It is 
then injected into the patient, best intramuscularly, 
using the triceps, outer regions of the thighs, the 
calves and gluteal regions. In young children one-half 
ounce, in older chil3ren. and adults one ounce is 
injected in each place. The injections may be repeated 
at intervals of four to five days. In early toxic or 
malignant cases he found frequently a critical drop in 
temperature, a disappearance of delirium, fading of 
the rash, improvement of circulation and general 



MEASLES 77 

improvement occurring rapidly after the injection of 
the convalescent blood. In later septic cases he found 
the injection of the whole blood from normal cases 
to have nutritive and stimulating properties. In septic 
cases, when the prognosis is doubtful or poor, the 
treatment should invariably include the administration 
of this harmless yet frequently efficient remedy. 

MEASLES 
THE PROPHYLAXIS OF MEASLES 

Measles is a disease to which practically every 
person who has not already suffered an attack is sus- 
ceptible. It is one of the most contagious of dis- 
eases. This was particularly evident in the large 
epidemics of measles attacking our troops during the 
mobilization on the Mexican border and those which 
occurred in the cantonments. 

It seems almost invariably true that one attack of 
the disease is protective, though a second, third, and 
even fourth attack sometimes occurs. It is probable 
that many of these so-called repeated attacks are some 
other disease, as German measles, or eruptions due to 
food poisoning. 

It has been observed that children under six months 
of age are less likely to take this disease than older 
children, and that extremely old people are also less 
susceptible. It seems to be a fact that the disease is 
most disastrous in its effects on infants, on persons 
who are tuberculous or who have any tendency to 
tuberculosis, on those who are debilitated from any 
cause, and on women who are pregnant or who have 
recently been confined. 

Efforts should be made, therefore, to isolate children 
who are suffering from measles in order to prevent 
the spread of the disease. 

The contagious material of measles appears to have 
less vitality and to resist the ordinary measures of 
disinfection, including sunlight and fresh air, much 
less strongly than does the contagium of scarlet 
fever. It seems to exist in the secretions from the 
nose, throat and mouth, and the disease seems to be 



78 MEASLES 

especially contagious during the period when the 
catarrhal symptoms are manifest but before the cuta- 
neous eruption appears. This increases the difficulty 
of enforcing efficient quarantine. When the disease 
is prevalent, children who show symptoms of cold in 
the head should be suspected of having measles and 
carefully watched, but at the beginning of an epidemic 
it is rare that a child will be placed in quarantine 
before the eruption has appeared. The Koplik spots 
appear in the mouth within three days before the 
catarrhal symptoms develop. Their appearance should 
be indication for immediate quarantine. 

The measures applicable to cases of measles may be 
briefly summarized as follows : 

The isolation of the patient in a remote room of 
the house. 

The selection of a single immune person to care 
for the patient. 

The wearing by the physician of a linen or rubber 
coat when he visits the patient, which is removed 
outside of the patient's door. 

The destruction of books and toys which have been 
used by the patient, at the end of the period of 
quarantine. 

The disinfection of dishes and clothing before they 
are removed from the sickroom. 

At the end of the period of quarantine, which in the 
case of measles unattended by complications should be 
three weeks, the bathing and shampooing of the 
patient and dressing him in fresh clothes. 

The disinfection of the room, after it has been 
vacated, by exposure of the room so far as possible to 
fresh air and sunshine. 

Sunshine and light are essential to the killing of the 
germs of all disease, and especially of measles; hence 
the room of a patient suffering from measles should 
only rarely be kept dark during the day. The patient's 
eyes may be efficiently protected from light by blue or 
smoked glasses. 

It has been suggested that children may be protected 
against measles by the injection of from 7 to 25 c.c. 



TREATMENT OF MEASLES 79 

of the serum of convalescent patients, but there is as 
yet not sufficient evidence for the routine use of this 
procedure. 

The prolonged cough of measles after the period of 
quarantine is over should be treated as though the 
patient had incipient tuberculosis, and the number of 
secondary deaths from measles will be cut in half. 

The secondary respiratory infections of measles are 
so serious that it may be considered advisable for both 
patient and attendants to wear gauze face masks as 
soon as convalescence begins. Droplet infection is 
thus inhibited. 

TREATMENT 

A patient with measles must be isolated. The room 
must be warm, as these patients should not be sub- 
jected to cold drafts or cold air. Chilling is espe- 
cially harmful in measles, because of the frequency of 
lung complications. This does not mean that the air of 
the room should not be fresh and clean, and the ventila- 
tion the best possible. 

Eyes. — Unless the child is very young and cannot 
wear colored spectacles, the room should not be dark. 
Sunlight is as essential for the welfare of patients 
with measles as it is in any other disease. It is 
absolutely unnecessary, in ordinary cases, to have the 
room black dark on account of the eyes. If the eyes 
are inflamed, the child will cooperate and really enjoy 
using colored spectacles. Of course, when it is time 
for the child to go to sleep, the room may be dark- 
ened, and the glasses removed. 

A saturated boric acid solution may be used as a 
wash for the eyes, and if it seems advisable, some sim- 
ple eye-drops may be used, such as : 

Gm. or C.c. 

B Acidi borici 1 25 gr. v 

Aquae camphorae 15 A3 ivss 

Aquae q. s. ad. 25 1 AS i 

M. Sig. : Use as eye-drops three or four times a day. 

If the lids tend to stick together after sleeping, 
they should be gently washed with warm boric acid 
solution or plain warm water, and before the child 



80 MEASLES 

goes to sleep the edges of the lids may be anointed 
with thick white petrolatum. 

Cough, etc. — If old enough, the child should gargle 
several times a day with some simple, warm, alkaline 
sedative solution. If the child is not old enough to 
gargle, the throat should be sprayed. The nose should 
also be sprayed occasionally, if it seems to be occluded 
by the secretions. It is often well to leave the nose 
alone in measles. Most nasal douching is inadvisable, 
as tending to force fluid or secretions into the eus- 
tachian tubes. 

Most of these patients require some simple expec- 
torant mixture, although many physicians are losing 
faith in the activity of so-called expectorant drugs. 
There is no safe drug that promotes the secretion of 
the mucous membrane of 'the upper air passages and 
bronchial tubes more than does ammonium chlorid. 
It is of advantage in causing the cough to be less dry, 
and therefore aiding the expulsion of any mucopuru- 
lent matter that may be in the trachea and bronchial 
tubes. If the cough is excessive from irritation, a 
sedative may be added to prevent the unnecessary 
coughing. A child 5 years old may receive : 

Gm. or C.c. 

B Codeinae sulphatis 05 gr. j 

Ammonii chloridi 3 3 i 

Syrupi tolutani 50 AS ii 

Aquae q. s. ad 100 A3 iv 

M. Sig. : A teaspoonful, in water, every two or three hours, 
when the child is awake. 

If the child's cough is not excessive or irritating, 
the codein may be omitted from the mixture. As 
soon as the expectoration is more free and there is no 
excessive amount of coughing, the medicine may be 
stopped. A child 10 years old should receive twice 
the amount of codein sulphate, and the ammonium 
chlorid should be increased to 5 gm., and if deemed 
advisable, the sour sirup of citric acid may be sub- 
stituted for the sweet sirup of tolu in amount of 25 c.c. 
to the 100 c.c. mixture. 

Because of the frequency of bronchopneumonia fol- 
lowing measles all lung symptoms should be carefully 
watched. 



TREATMENT OF MEASLES 81 

Bowels. — In the beginning of the disease, the child 
should receive a dose of castor oil, or some cascara; 
the bowels should be thoroughly and well moved. 
Minute doses of calomel frequently repeated should not 
be given, as such dosage causes irritation, and medica- 
tion may cause an enteritis, a not infrequent complica- 
tion of measles. Subsequently the bowels may be 
moved daily with some gentle laxative if needed. 

Diet. — The food depends on the temperature and 
should be milk and cereal gruels as long as the temper- 
ature is elevated. As soon as the temperature falls 
to normal, the child should receive good nutritious 
food, and plenty of it. It is inadvisable to give meat 
in any form, including broths, as long as the eruption 
is present. If, as has been suggested, the eruption 
in measles is caused by some irritant circulating in 
the blood, such as occurs in urticaria, representing a 
sort of anaphylaxis, the proper diet comprises cereals, 
milk, and plenty of water. 

Fever. — The temperature rarely calls for much 
treatment. If it is high, however, one or two doses 
of acetanilid will generally be sufficient to reducfe it. 
Warm sponging will cool the child as much as cold 
sponging will, and with less disturbance. Cold spong- 
ing in measles is inadvisable. As often as the child 
is bathed or sponged for temperature, the surface of 
the body should be powdered with some bland talcum. 

Skin. — Unless the room is cold and damp, or the 
patient is otherwise ill, a cotton nightdress will cause 
less itching and discomfort than would a warmer flan- 
nel or silk shirt. All through- the illness the nurse 
should recognize that it is the secretions of the nose 
and throat that cause infection of others, and not 
the eruption or exfoliation from the skin. This does 
not mean that it is not necessary to sterilize the 
child's garments and bedclothing, as such may carry 
the infection from the nose and throat. 

Convalescence. — Prolonged, careful convalescence 
is essential in measles. Measles, like whooping cough, 
is often a forerunner of pulmonary tuberculosis, 
or more acute lung complications. Probably every 
attack of measles causes enlargement and more or less 



82 WHOOPING COUGH 

inflammation of the bronchial glands. If such glands 
harbor tubercle bacilli, they are stimulated to cause an 
acute infection. On the other hand, immediately after 
an attack of measles a patient is doubtless more sus- 
ceptible to infection from tubercle bacilli. Therefore, 
before the child is returned to school the cough should 
have ceased, his weight should be normal, and his 
nutrition should be good. 

Persistent enlarged glands in the neck or elsewhere, 
and adenoid conditions or enlarged tonsils, should all 
be regarded with suspicion. Such conditions are 
liable to be accentuated by an attack of measles, and 
proper treatment should be instituted. A suppurating 
ear must be treated by a specialist until it is pro- 
nounced cured and the hearing is as near perfect as 
possible. The physician should remember that most 
defective ears follow measles, scarlet fever and influ- 
enza; that an acutely infected ear, if immediately 
correctly treated, is generally saved intact; distention 
and perforation may occur without pain. Conse- 
quently, he should be ever alert to see that the compli- 
cation of middle-ear inflammation is immediately 
treated. 

WHOOPING COUGH 

THE PROPHYLAXIS OF WHOOPING COUGH 

The great mortality of whooping cough is indirect. 
A large number of those infected die of such complica- 
tions as bronchial pneumonia, capillary bronchitis, 
tuberculosis and a few from hemorrhages, while 
chronic debility, anemia, emphysema, and some lesion 
of the central nervous system are of not infrequent 
occurrence. In young children and infants, whooping 
cough causes more deaths than measles, and some 
statistics show twice as many deaths as measles ; 95 
per cent, of deaths from whooping cough occur during 
the first five years of life, and the majority of these 
during the first two years. 

It is pretty well proved that the Bordet-Gengou 
bacillus is the cause of this disease. It seems to be 
established that the greatest infectivity occurs during 
the initial stages of whooping cough, and that even 



CAUSE OF WHOOPING COUGH 83 

during the active paroxysmal stage there is less lia- 
bility of infection of others, and in the later stages 
the causative germ is absent. 

The Bordet-Gengou bacillus is a minute bacillus, 
occurring in large numbers among the cilia of the 
epithelial cells of the mucous membrane of the trachea 
and bronchi. It is stated that the germ does not grow 
above the larynx, although of course by coughing it 
reaches these parts. 

This disease occurs largely in epidemics, and young 
children and babies are apparently most susceptible to 
infection. This may be more apparent than real 
from two reasons: first, because young children, 
necessarily remaining more in the house, are liable 
more frequently to come in contact with concentrated 
infected matter if an infected person comes near them ; 
and, second, because a large number of older children 
and the majority of adults have probably had the 
infection and have become immune. However, when 
an adult or elderly person acquires the disease it is 
almost invariably severe. The muscular strength of 
adults makes the paroxysmal coughing of much greater 
danger; they are more liable to emphysema, heart 
strain and hemorrhage. They are not so liable to have 
pneumonic complications. Whooping cough, however, 
even in adult life, is a not infrequent stimulator of a 
latent tuberculosis. Often an adult, who is in close 
contact with a whooping cough patient, and who may 
have had the disease in childhood, develops a mild 
form of the disease; at least he has the catarrhal 
symptoms and coughs, more or less spasmodically. 
Whether the Bordet-Gengou bacillus is present in 
these cases has not been determined. It is a fact, how- 
ever, that ordinarily one attack of the disease renders 
a person immune. 

The incubation period of pertussis is not definitely 
known, and may vary from two to ten days ; therefore 
before it is considered safe for a child exposed to this 
infection to return to school or to play with other 
children, at least ten days must have elapsed, and 
perhaps a better working rule is two weeks. 

Pathologically, the disease manifests itself by a 
catarrh of the upper bronchial tubes, trachea, larnyx 
and perhaps pharynx and nose. The secretion is 



84 WHOOPING COUGH 

mostly mucus, with perhaps, later, a mucopurulent dis- 
charge from secondary infection. A severe paroxysm 
of coughing, or a prolongation of paroxysms, may 
cause hemorrhages ; perhaps more or less emphysema ; 
always cardiac strain, and perhaps cardiac dilatation; 
and frequent paroxysms, anemia and emaciation. 
Hemorrhages may occur from the nose, in the eyes, or 
even in the brain. 

The cough is laryngeal in type, is at first dry, and 
later becomes spasmodic and paroxysmal, thus differ- 
ing from that of ordinary colds; that is, the coughs 
occur in series, more or less periodically, or in showers. 
With these paroxysms there is more or less closing 
of the larynx, with the attempt at inspiration through 
a narrowed glottis, which causes the characteristic 
whoop. These paroxysms increase in frequency as the 
disease progresses, and are precipitated by any change 
in the atmosphere and by suddenly breathing in cold 
air, as by laughing, and even by swallowing food, and 
they sometimes occur without any apparent cause, 
because of irritation from the germ and its conse- 
quences. The number of paroxysms in twenty-four 
hours varies, but there may be as many as fifty. Early 
in the disease there may be a slight fever. 

TREATMENT 

Unless the patient has considerable rise of tempera- 
ture, it may not be necessary to put him to bed, but, 
especially with children, the paroxysms are generally 
diminished if the child is kept in bed for a time, or at 
least kept quiet. The more active the child, the more 
paroxysms. Consequently, even without fever, if a 
child vomits almost every meal, or if he coughs so 
severely as to cause hemorrhage, or shows that the 
right side of the heart is becoming strained (which is 
the side of the heart most affected), he must be put to 
bed and remain there. 

The actual treatment of this disease may be divided 
into four heads : (1) to prevent the infection of others ; 
(2) to shorten the disease, if possible; (3) to diminish 
the severity of the paroxysms; (4) to treat complica- 
tions as they occur. 

The first indication has already been considered. 



THE DIET IN WHOOPING COUGH 85 

The second indication is met by general hygiene and 
by drugs. Fresh air and sunshine, without exposure, 
are among the greatest mitigators of this disease. If 
the weather is pleasant, the child should be outdoors 
or on a veranda most of the time. If the weather is 
such that it is impossible to remain outdoors, he should 
be isolated in one, or better, in two large rooms, so 
that while one room is being thoroughly aired and 
cleansed he may go to the other one. There seems to 
be no question that the more infected or polluted the 
atmosphere of a room, the more the child will cough. 

The Diet. — If the child vomits a meal as soon as 
he has eaten it, during a paroxysm, in a few minutes 
he should be given food again, with the probability 
that the next paroxysm will not so quickly occur but 
that the food may remain in the stomach and be 
digested. A child that receives insufficient nourish- 
ment from any reason should be given food more fre- 
quently.- The character of the food should depend on 
his condition, and should be that which is found to be 
less frequently vomited. The best diet is cereal and 
vegetable, with milk and eggs. The end-products of 
meat metabolism are likely to raise the excitability and 
irritability of any one whose nervous system is irri- 
tated. For this reason meat should not be given, and 
no tea or co'ffee. A patient who is not allowed meat 
should receive a small dose of iron once or twice a 
day. Calcium in any simple form may be used as a 
nervous sedative and a nutrient. Hot baths before 
going to bed relax the nervous system and quiet the 
patient. Also massage is sometimes soothing. Of 
course, it is always essential to have the bowels move 
daily. Plenty of water should be given the child, as 
the more moist the mucous membranes, the less they 
are irritated, and the less frequent the paroxysms. 
For this object many inhalants have been devised. 
Perhaps the most important element of these inhalants, 
whether sprays or steam, is the water that they con- 
tain. Sometimes bland petroleum oils atomized and 
inhaled soothe the irritated mucous membranes. 

Various antiseptics have been suggested. Antipyrin 
as a spray and gargle has been much used as a germi- 
cide in from 5 to 10 per cent, strength, and has been 



86 WHOOPING COUGH 

much lauded in this disease. Quinin sprays, though 
more disagreeable, have been used in the throat as 
germicides. Various combinations with thymol and 
eucalyptol, and other mild aromatic antiseptics, have 
been used as sprays and gargles or inhalants. It is 
quite probable that a creosote or other antiseptic 
inhalant may inhibit the growth of germs in the 
trachea and upper large bronchi, provided the patient 
is old enough to cooperate and inhale the vapor into the 
lungs to that depth. As an application in the pharynx 
and mouth, hydrogen peroxid solutions, 1 :5, would be 
as efficient as anything that could be offered. Manj 
times, however, these "antiseptic" inhalants or atomi- 
zing substances cause irritation and paroxysms, and 
must be abolished, while mild alkaline solutions, well 
represented by % teaspoonful of sodium chlorid and 
}4 teaspoonful of sodium bicarbonate in a glass of 
warm water, cleanse and soothe the throat without 
causing paroxysms. 

There are still many who believe that quinin given 
internally will shorten the disease. It has not yet been 
shown that quinin inhibits the growth of the Bordet- 
Gengou bacillus. If there is any tendency to secondary 
infection in the nasopharynx, with congestion of the 
ears, of course quinin should not be given, 

The vaccine treatment aims to shorten the disease, 
but the exact value of vaccine in this disease has not 
been demonstrated. Thousands of cases have been 
vaccinated, and yet there is considerable doubt as to 
whether the vaccines are of much benefit. 

Immunizing doses, to prevent the development of 
the disease in other children of the family, have been 
given in doses of 20 million bacilli, and the dose 
repeated four or more times, and the disease has been 
apparently prevented by such vaccination. Hess, who 
made a careful study of the vaccine treatment of 
whooping cough, was disappointed in this treatment 
of the disease ; but he did find that in a certain per- 
centage of cases immunizing doses prevented the 
development of the disease. 

The third indication, namely, to diminish the sever- 
ity of the paroxysms, is of great importance. It has 
already been stated that the more quiet the child, the 



MEDICAL TREATMENT OF WHOOPING COUGH 87 

less frequent will be the paroxysms. Also, if the child 
lies down as soon as he begins to cough, he is less likely 
to vomit. An elastic abdominal belt seems to be of 
value in controlling the vomiting and the paroxysms 
of young infants especially. In some patients the 
paroxysms are so severe that chloroform inhalations 
have been given to prevent the intensity of the spasms. 
It has been stated that inhalations of chloroform 
actually lengthen the time between the paroxysms and 
shorten the disease. Chloroform inhalations may act 
as a germicide. On the other hand, the frequent 
administration of chloroform, even in small doses, is 
known to injure both heart and kidneys. 

The most effective of all medicinal treatments is 
antipyrin and digitalis. A very good rule for the 
dosage of antipyrin is 0.05 gm. (about 1 grain) for 
every year of the child's age. This should be given 
three or four times a day, depending on the frequency 
of the paroxysms. It should not be continued indefi- 
nitely nor used to excess. Of course this rule is not 
applicable for higher ages. The frequency should be 
diminished as the frequency of the paroxysms dimin- 
ishes. Coincident with the antipyrin should be given 
digitalis in the form of the tincture, and in the dose 
proper for the child's age, and determined by its effect, 
on the child's heart and pulse. The heart needs help, 
both from the strain of the disease and also as anti- 
pyrin might cause some weakening of the heart. The 
antipyrin acts by causing less irritability of the nervous 
system and relaxing muscle spasm. Even though the 
drug has disadvantages, its disadvantages are much 
less than the harm caused by the whooping cough 
paroxysms. 

The bromids have been frequently given in large 
doses. They act by inhibiting the reflex activity of the 
nervous system and by more or less dulling the periph- 
eral nerves in the throat and upper air passages. 
Chloral has been used in order to depress the nervous 
irritability. Atropin or belladonna have been given in 
large doses ; their value is due to the dulling of the 
peripheral nerves in the irritated part of the body. 
However, atropin is a stimulant, and cannot have much 
good effect in this disease, unless the dose is very large, 



88 WHOOPING COUGH 

and with such large doses atropin intoxication readily 
occurs, that is, the pulse becomes rapid, the throat dry, 
the face flushed, and there is likely to be cerebral 
excitation and perhaps dilated pupils. 

Antipyrin is best given, to a child, in solution, as 
follows : 

Gm. or C.c. 

B Antipyrinae 51 3 iss 

Aquae menthae piperitae... 100| fl5 iv 

M. et Sig. : A teaspoonful, in water, three or four times a 
day. 

This dosage is for a child 5 years old. Antipyrin is 
also available in the form of sweet flavored soft tablets 
which children will take readily. 

Various hydrotherapeutic measures are often of 
value, and the hot bath is always useful in quieting the 
patient and relieving internal congestions. 

The fourth indication, namely, to treat complications 
as they occur, is almost supererogation, as each com- 
plication calls for its proper treatment. However, 
under this heading the prevention of such complica- 
tions may be urged. Vomiting may be prevented by 
quiet, rest for a while after eating, by the abdominal 
belt and by proper food. Nutrition must be kept up 
at any cost, and, if necessary, the child be given simple 
liquid nourishment every three hours. Not infre- 
quently cod-liver oil is well borne and is an oil-nutri- 
ment of great value. Anemia must be prevented by 
iron. If it is seen that the heart is becoming strained, 
and the face and throat remain congested even after 
the paroxysm is over, showing that the right ventricle 
is in trouble, digitalis should be given and such rest as 
would be given any damaged heart. This treatment 
also tends to prevent hemorrhages. Even if the child 
is weak and the circulation is weak, strychnin is inad; 
visable, as it stimulates the nervous system and causes 
or allows more paroxysms to occur. 

If the child has a history of enlarged glands or 
recurrent colds, or has inherited a tendency to tuber- 
culosis, or tuberculosis has been present in the child's 
family, its convalescence after whooping cough should 
be prolonged, and country or seashore air should be 
urged where possible. Certainly, such a child should 



DIPHTHERIA 89 

not be confined in school until its nutrition has become 
as good as before the infection with whooping cough 
occurred. 

DIPHTHERIA 

This throat inflammation has been known for cen- 
turies, having first appeared in the East and later in 
Europe, occurring mostly in epidemics. A carrier of 
this disease may communicate it to persons widely 
separated. While nearly all mankind is susceptible to 
smallpox, and a large majority to scarlet fever, many 
persons seem naturally immune to diphtheria. A closer 
contact is apparently needed with an infected person 
than in these other diseases. 

This disease has always had a large percentage of 
deaths ; but the death rate since the introduction of 
antitoxin has been constantly on the decrease, and with 
a better understanding of the proper dosage of anti- 
toxin, and with the effort made to diagnose the disease 
early, the death rate will be more rapidly decreased. 
Our best sanitarians believe that for every case of 
diphtheria recognized, at least one sore throat that car- 
ries the Klebs-Loeffler bacillus escapes ; in other words, 
there is an equal number of missed mild cases. 

It has been shown that the normal hydrochloric 
acid in the stomach inhibits or kills the diphtheria 
bacilli ; therefore it is exceedingly rare to find these 
germs in the intestines, and very rare to find diph- 
theritic membrane in the stomach. 

In the majority of cases the tonsils, one or both, are 
the parts affected in diphtheria, and with the present 
methods of treatment, in a large portion of these cases 
the membrane will be limited to these regions. The 
soft palate is next most frequently attacked, the 
pharynx next, and nasal diphtheria, with proper care 
taken, is not very frequent. Laryngeal diphtheria is 
not a frequent complication of tonsillar diphtheria; 
when it occurs it generally begins as the original point 
of attack. 

CARRIERS 

Diphtheria carriers may be convalescents, or those 
who have had contact with diphtheritic patients. The 
latter group may or may not later develop the dis- 



90 DIPHTHERIA 

ease. The term may be perhaps more properly limited 
to those who carry the germ for months. Diphtheria 
germs may live a long time on books or other sub- 
stances, handled, coughed, sneezed on or expectorated 
on by a diphtheria patient, and may infect persons 
coming in close contact with such infected material. 
This method of infection may not be very frequent. 
Animals may carry the infection. It is doubtless a 
good axiom to believe that a tonsillitis with exudate 
is diphtheria until it is proved not to contain the 
Klebs-Loeffler bacillus. Such a patient should be 
isolated, as streptococcic infection is, if anything, more 
readily communicated than is a diphtheria infection. 
Therefore, there can be no excuse for not isolating a 
sore throat with exudate or membrane as soon as such 
a case is discovered. 

The location of the Klebs-Loeffler bacillus in car- 
riers who are convalescing is probably most frequently 
in the throat, though the bacillus may be found in the 
nose. In those who carry these germs long they are 
more likely to be found in the nose. Therefore, 
swabs should be taken from both regions. It is quite 
probable that a surface swab from a tonsil may be 
negative while a culture obtained from probing into 
crypts of the tonsils or in the region back of the tonsil 
might show the presence of the germ. It is culpable 
neglect to fail to examine a patient thoroughly to 
ascertain if he is free from the Klebs-Loeffler bacillus. 

The boards of health vary as to the number of nega- 
tive cultures that will release a patient from quaran- 
tine. The safest number is perhaps four negative cul- 
tures, two from the throat and tonsils, one from crypts 
or back of the tonsil, and one from the nose, taken on 
alternate days, at a considerable interval from the use 
of any antiseptic washes, gargles or sprays. This 
would seem to prove that a patient was free from the 
Klebs-Loeffler bacillus. 

TREATMENT OF CARRIERS 

Various methods of ridding a carrier of the diph- 
theria germs have been tried. Local measures vary: 
they may comprise painting the suspected regions with 
tincture of iodin or with Lugol's solution, with silver 



DIPHTHERIA CARRIERS 91 

solutions, phenol solutions, or the use of various gar- 
gles, hydrogen peroxid solutions, etc., and the nasal 
inhalation of various thymol or iodin inhalants or 
sprays. There is no question that whatever else is 
done, some local antiseptic should be applied. Diph- 
theria antitoxin injection has not been very success- 
ful. Local applications in the mouth, throat or nose 
of antidiphtheritic serum have not been proved to be 
very successful. Vaccinations with dead diphtheria 
bacilli have been only partially successful. Albert states 
that a local application to suspicious crypts of the 
tonsils of a "5 per cent, solution of silver nitrate will 
destroy all bacteria with which it comes in contact." 
A thorough application of a 10 per cent, solution of 
silver nitrate he finds will cause some destruction of 
the epithelium of a crypt and a fibroblastic prolifera- 
tion with ultimate obliteration of the lumen, which is 
of course the object desired. 

Hektoen and Rappaport found that, when properly 
applied, kaolin in the form of a dry powder removes 
not only diphtheria bacilli but also practically all bac- 
teria from the nose in the course of from three to four 
days. For this purpose the kaolin is blown into the 
nose six or seven times a day at two-hour intervals by 
means of a rubber bulb attached to a glass tube, the 
free end of which tapers a little. The insufflation is 
repeated several times at each treatment. The success 
of this treatment appears to depend largely on the free 
and thorough distribution of kaolin over the nasal sur- 
faces. In cases of more or less obstruction of the nasal 
passages, the removal of bacteria by insufflation is 
more difficult. 

In order to secure the most thorough application of 
kaolin to the mucous membrane of the throat, patients, 
if old enough, are instructed to swallow as slowly as 
possible one-third teaspoonful of kaolin four or five 
times an hour during the day. In the case of adults 
and older children who are anxious to get rid of 
diphtheria bacilli, this method, which has been selected 
after trial of several others, involves no special 
difficulty. 

A careful examination of carriers frequently discloses 
some local condition which allows the bacteria to live 



92 DIPHTHERIA 

and grow and which prevents their being reached by 
any local application. Friedberg studied such cases 
after removing the tonsils and found that cultures 
became negative at once or very shortly. Similar 
favorable results from tonsillectomy have been 
reported by other clinicians and laboratory workers. 
There seem to be no contraindications to the operation 
aside from those obtaining in other conditions. Local 
conditions in the nose and throat other than those in 
the tonsils may determine the presence of the bacilli 
and should be sought and relieved whenever possible. 

• 

IMMUNITY 

While it has been long known that infants and many 
adults seem not to be susceptible to diphtheria, it has 
only lately been shown that probably a large propor- 
tion of adults, stated at 90 per cent., perhaps 50 per 
cent, of children, and perhaps 80 per cent, of new- 
born infants have diphtheria antitoxin in their blood 
and are not likely to become ill with diphtheria. 

A skin test has been devised, known as the Schick 
reaction, to determine whether or not a person is pro- 
tected against diphtheria, that is, whether he has diph- 
theria antitoxin in his blood. The reaction distinctly 
shows that a person is artifically protected or has 
natural antitoxin against this disease. The test is made 
with a dilute diphtheria toxin of such strength that 
0.1 c.c. contains one-fiftieth of the minimum fatal dose 
for a guinea-pig. This amount, namely, 0.1 c.c, is 
injected between the layers of the skin, perhaps best 
on the inner surface of the arm. A positive reaction 
should appear in from twenty- four to forty-eight 
hours, and is evidenced by a slight swelling and local- 
ized redness, a reddened papule which remains from 
seven to ten days. When this papule disappears, the 
skin over it may desquamate slightly, and pigmentation 
may remain for days and even weeks. The injection is 
best given with a small hypodermic syringe with a 
platinum point needle, it must be into the skin and not 
subcutaneously, and immediately after the injec- 
tion there should be a raised whitish spot, which in 
twenty-four hours becomes bluish, with a slight edema. 
Schick's interpretation of the positive reaction, as just 



IMMUNIZATION AGAINST DIPHTHERIA 93 

described, is that the patient has no antitoxin in his 
blood, or at least less than 1/30 unit of antitoxin in 
1 c.c. of blood. Pie declares that all persons so react- 
ing are susceptible to diphtheria. Park, in his summary 
on immunity in diphtheria, states that according to 
Hahn the interval between the injection of vaccine and 
the development of antitoxin is not less than three 
weeks, while other investigators think that it may be 
eight days. Persons who have a natural antitoxin 
show an earlier increased antitoxin production. Von 
Behring considers that 0.01 unit of antitoxin per 1 c.c. 
of blood is sufficient to protect a healthy individual, 
and much less may protect against diphtheria. 

Immunizing doses of antitoxin to persons who have 
been exposed to diphtheria, given early, are generally 
successful in preventing the development of the dis- 
ease. The immunizing dose for a child should prob- 
ably be at least 1,000 units. Adults may receive larger 
doses. 

IMMUNIZATION WITH TOXIN-ANTITOXIN 

It has been shown through research that a more 
durable immunity against diphtheria is established by 
the use of a mixture of diphtheria toxin and diphtheria 
antitoxin than by the latter alone. The immunity does 
not appear until a considerable period of time has 
elapsed and for this reason the mixture is not espec- 
ially useful at the time of an outbreak of diphtheria. 
At these times it is probably better to rely on the 
diphtheria antitoxin alone. 

Various mixtures of toxin and antitoxin have been 
suggested and numerous preparations are on the mar- 
ket and have been described in New and Nonofficial 
Remedies. Most clinicians advise the overneutralized 
mixtures, for instance five lethal plus doses of toxin 
to 6.25 units of antitoxin. Several doses are usually 
required to produce immunity. These preparations are 
especially useful in schools, asylums, homes, etc. and 
among those persons who frequently come in contact 
with diphtheria patients, such as physicians, nurses and 
attendants in contagious disease institutions. 

Zingher has suggested that all infants below twelve 
months and, if possible, below eighteen months of age, 
be actively immunized with three doses, each 10 c.c. of 



94 DIPHTHERIA 

the toxin-antitoxin mixture. The injections are given 
subcutaneously in the arm or below the angle of the 
scapula, and repeated every seven days. In older chil- 
dren he advises the use of the Schick test as an indica- 
tion for immunization. 

Toxin-antitoxin immunization has now been tried 
on thousands of cases with markedly successful results 
and in the presence of cases of diphtheria in the home 
or of an epidemic in the community, its use for immu- 
nization should have early consideration. 

TREATMENT 

A. Isolation. — It should be again urged that a throat 
with spots or membrane should be considered as likely 
to be diphtheritic until a culture has proved it not to be. 
Such a patient should be isolated in the best' room 
available, looking toward the possibility of the dis- 
ease being diphtheria and a nurse being required. 
Other children of the family must be excluded from 
contact with this patient. If the case is clinically one 
of follicular tonsillitis, the physician may wait for a 
positive test before giving antitoxin. If, however, the 
case is clinically diphtheria, antitoxin should be given 
without waiting for a report, provided there is 
nothing in the history of the patient to show that 
there will be any hypersusceptibility to horse serum. 
Whether it is follicular tonsillitis, or other strepto- 
coccic infection, or diphtheria proper, gargles and 
local cleanliness of the throat should be immediately 
inaugurated, and when this is properly carried out, 
the danger of infection of others is reduced to a 
minimum. 

It is hardly necessary in this day, in which the 
advisability of sunlight, a large room, an adjacent 
bathroom, the absence of all unnecessary draperies, 
furnishings, rugs, etc., for a proper isolation room are 
so well understood, to describe again the needs in 
detail. Instruction should be given the family in the 
minor details of the prevention of infection of others. 
A properly trained nurse well understands the necessity 
for burning wooden tongue depressors, wooden appli- 
cators, the gauze and cotton used around the patient's 
nose and mouth, and washcloths; the use of liquid 



GENERAL CARE IN DIPHTHERIA 95 

soap; simple but effective cleanliness of the patient's 
face, hands, and body ; boiling of all eating and drink- 
ing utensils ; disinfecting the toothbrush with non- 
poisonous germicides ; allowing the bed clothing and 
bed garments to stand in germicidal solutions before 
being sent to the wash ; frequent washing of her own 
hands in germicidal solutions; and gargling her own 
throat with various solutions. 

B. General Care of Patient. — High fever is not fre- 
quent in diphtheria, unless the case has been neglected. 
Consequently, the patient should receive, almost from 
the beginning, plenty of nutritious food. The exact 
diet, of course, depends on the age of the patient. 
Milk, oatmeal gruel, eggs, meat juice well salted, toast, 
butter, and the whole, or the juice, of one or two 
oranges, would represent the food needed. With or 
without meat, it is well to give a diphtheria patient 
iron, and no preparation is better than the tincture of 
iron chlorid in 5-drop doses, three times a day, given 
in fresh lemonade or orangeade, after nourishment. 

However well the gastric juice inhibits the growth 
of the bacteria, it is always wise for a patient to gar- 
gle, or be sprayed, before taking food, so that the 
mouth and throat will be as clean as possible. 

The bowels should be moved daily by some simple 
laxative, if they do not move without such help. 

While a diphtheria patient should have plenty of 
fresh air and all the sunlight possible, he should be 
kept warm. He should not be allowed to become 
chilled, as the toxins of this disease cause depression 
and the patient's temperature may be quite low, and 
the hands and feet easily become cold. Even if the 
temperature is high, the bathing should be by warm 
sponge baths. 

C. Antitoxin. — Recent investigations by Schick 
show that the dose of antitoxin advisable for ordinary 
cases of diphtheria can be based on the weight of the 
patient. Schick finds that 100 units of antitoxin 
per kilogram of weight is sufficient to combat the toxin 
in diphtheria in all ordinary cases, and in severe cases 
500 units per kilogram is more than sufficient. In 
other words, enormous doses of antitoxin are not 



96 DIPHTHERIA 

needed. This is especially true if the antitoxin is 
given early. A kilogram equals 2 1/5 pounds avoirdu- 
pois, and a child weighing 45 pounds, in an ordinary 
case of diphtheria, should be given 2,000 units of 
antitoxin ; while if the case is severe, or in nasopharyn- 
geal or laryngeal types, 10,000 units would be all 
sufficient. By the same method of decision as to the 
dose, an adult of about 130 pounds should receive 
6,000 units in a mild case, and 30,000 units if the 
diphtheria is of malignant type, or has affected parts 
where the danger of absorption is greater. 

It seems quite probable that if such doses can be 
administered on the first day of the infection with the 
Kkbs-Loeffler bacillus, no more antitoxin will be 
needed in such cases, and that death from this disease 
will be reduced to a minimum. 

Smith and Park have shown that when antitoxin 
is given subcutaneously, it takes from three to four 
days before the maximum amount of antitoxin is cir- 
culating in the blood. If the antitoxin is given intra- 
muscularly this period is shortened. From these find- 
ings, therefore, the conclusion should be made that 
if the case is urgent and the toxemia serious, anti- 
toxin should be administered intravenously; if the 
case is severe and the diagnosis has not been made 
early, antitoxin should be given intramuscularly; in 
ordinary or mild cases, and on the first day or two of 
the disease, it may be administered subcutaneously. 

The possibility of an anaphylactic reaction should 
not prevent the use of antitoxin in a patient with diph- 
theria, even though he has previously received anti- 
toxin for immunologic or curative purposes. In such 
persons it is advised to give a small amount (from 
0.1 to 1 c.c.) subcutaneously; if no severe symptoms 
appear after one or two hours, the full dose may be 
given. 

Several considerations make it difficult to state the 
probability of appearance of anaphylactic phenomena 
in any given case. In addition to individual peculiari- 
ties which no doubt play a part, the volume of serum 
injected and the method of preparation of the serum 
are important factors. Weaver (Arch. Int. Med., 



USE OF ANTITOXIN . 97 

June, 1909, p. 485) found that when the volume of 
serum was small (from 1 to 9 c.c.), serum disease 
(urticaria, erythema, arthritis, etc.) appeared in 10.9* 
per cent. ; with increasing volumes of serum, the per- 
centage of reactions progressively increased so that 
in those cases receiving from 80 to 280 c.c, serum dis- 
ease was noted in 61 per cent. The more recently 
developed methods of concentrating and refining anti- 
toxin yield serums of high potency, so that the neces- 
sary amount of antitoxin units is available in small 
volume of serum, and the probability of serum disease 
is accordingly decreased. The removal by the refin- 
ing process of certain albumin fractions of the serum 
decreases the* incidence of serum disease. The older 
statistics, therefore, probably show a higher incidence 
of reactions than are being obtained at present with 
concentrated serum. 

In persons receiving serum for the first time, serum 
disease appears in the majority of cases from the 
seventh to the tenth day, but sometimes earlier or much 
later, and rarely need cause alarm. Of 200,000 per- 
sons injected with serum, there was but one death from 
anaphylactic shock (Kolle). 

The reactions which follow reinjections of serum 
(that is, in persons previously injected) may be imme- 
diate, and in any case are likely to occur earlier than 
those after first injections (accelerated reactions). The 
immediate reactions usually present, in addition to 
urticaria and other symptoms of serum disease, symp- 
toms of respiratory disturbance, cyanosis, rapid pulse, 
etc., and correspond to the anaphylactic shock seen 
after reinjection of experimentally sensitized animals. 
Epinephrin and atropin have been used with benefit. 
Even these severe reactions are very rarely fatal. About 
50 per cent, of fatal instances of anaphylaxis have 
occurred in asthmatics, and in some of the latter the 
fatality followed the first injection of serum. When 
the reinjection is made within six days after the first 
injection in man there is practically no danger of ana- 
phylaxis ; reinjection in from three to eight weeks after 
the first injection is followed by some degree of ana- 
phylaxis in about 90 per cent, of cases; reinjection 
after six to nine months is followed by reaction in 
about 50 per cent, of cases (Seidel: Miinchen. med. 



98 DIPHTHERIA 

Wchnschr., 1915, lxii, 1210.) With the lapse of years 
the percentage of reaction on reinjection is further 
decreased, and usually appears as an accelerated reac- 
tion. 

The danger of serum reactions even in previously 
injected persons is so much more remote than the dan- 
ger from diphtheria that the physician should not 
hesitate to avail himself of so potent a remedy as anti- 
diphtheric serum. 

D. Care of the Throat. — It would be just as sensible 
to perform a major operation with the most perfect 
technic and .yet take no means whatever of preventing 
infection, as it is to administer antitoxin in proper 
dose in diphtheria and then to take no proper care of 
the throat. All odor and all danger of secondary 
infection are removed by proper treatment of the part 
affected. Although germicides cannot kill the germs 
deep in the mucous membrane, or those that are pro- 
tected by an overlying exudate, a certain large por- 
tion of the surface bacteria are surely killed by as 
simple a gargle as hydrogen peroxid solution. More 
active and more irritant germicidal gargles or germi- 
cides that are sources of danger when swallowed, are 
entirely unnecessary in diphtheria. 

If the child is old enough to gargle or swash the 
tonsils, this is the best method of cleansing the throat. 
If the child is not old enough, thorough spraying of 
the throat should be done. A solution of one part of 
the official aqua hydrogenii dioxidi to 3 parts of 
warm water, freshly prepared each time, should be 
used as a gargle, every one and one-half or two hours 
during the day, and every three hours during the 
night. Three or four minutes after this gargle has 
been used, it should be followed by some simple alka- 
line wash, to remove the irritant effects of the hydro- 
gen peroxid. A gargle that may be used for the sec- 
ondary cleansing purpose is a teaspoonful of boric 
acid added to % glass of warm water. This will not 
all dissolve, but will deposit on the throat and act 
as a mild antiseptic. Also, there is no greater pro- 
moter of mucous secretion of the throat than boric 
acid ; and the more the mucus is secreted, the quicker 
will the membrane be loosened. Or, a simple solution 
of % teaspoonful of salt and % teaspoonful of sodium 



CARE OF THE THROAT 99 

bicarbonate may be added to % glass of warm water. 
The object of such a gargle and wash is to cleanse the 
mouth and throat of froth and pieces of membrane, 
mucus, mucopus, etc., and to soothe the membrane. 
It is frequently advisable to insufflate boric acid 
directly on the masses of membrane or exudate. This 
should be done by the physician. 

After the throat has been cleansed, it is often of 
value to apply tincture of iodin to the membrane or 
exudate. Care must be taken not to touch the healthy 
membrane with this solution. Lugol's solution may be 
applied to the parts of the throat that are not affected, 
which often tends to prevent development of more 
exudate or membrane. If there are pockets and crypts 
in diseased tonsils, after cleansing such, boroglycerid 
may be applied to heal and to prevent spreading of 
infection. 

As frequent gargling is very tiresome for the throat, 
swashing is nearly, if not quite, as efficient, and should 
be suggested. If the child is too young to gargle or 
swash, the peroxid should be sprayed on, and the 
solutions for this purpose should be stronger, namely, 
1 part to 2 parts of warm water. The cleansing spray 
may be used afterward. If the throat and mouth gen- 
erally are irritated, a soothing gargle is as follows : 

Gm. or C.c. 

R Acidi borici 2| gr. xxx 

Potassii chloratis 5| 5 iss 

Aquae menthae piperitae... 200| fl£ vii 

M. Sig. : Use undiluted as a gargle, as directed. 

Of course, any other flavor than peppermint could 
be used in this mixture. 

Whether or not it is advisable to use a weak hydro- 
gen peroxid solution in nasal diphtheria is a question 
for individual decision of the physician; generally it 
is too irritant, even when used weak, and is inadvis- 
able. Cleansing mild alkaline solutions or boric acid 
solutions represent the most successful treatment of 
nasal diphtheria used as sprays or snuffed through the 
nostrils. Such mild, warm solutions may be poured 
from a small vial or from a teaspoon into the nostril, 
with the head thrown back. It is "inadvisable to use 



100 DIPHTHERIA 

any of the douches that are on the market, or any 
syphon douche, as the pressure is too great, and fluid 
is often forced up the eustachian tube or into some of 
the sinuses. Suprarenal extract may be added to 
these solutions, if deemed advisable, but it should not 
be used too frequently. Also, the nose should not be 
sprayed too frequently. 

As soon as the throat is clean, the frequency of the 
gargles should be diminished, but it should be several 
days before the patient is not awakened at night to 
gargle at least once, or better, twice. 

The treatment of the throat advised for diphtheria 
is equally applicable to follicular tonsillitis or scarla- 
tinal throats, and to septic sore throat. 

E. General Medication. — A diphtheria patient 
requires very little general medication, unless some 
complications occur. In the beginning a small dose of 
calomel, or a dose of castor oil may be advisable, and 
subsequently whatever simple laxative is needed to 
cause a daily movement of the bowels. The tempera- 
ture does not often call for treatment. If it is high, 
or there is headache and backache and general aches, 
two or three small doses of a coal-tar antipyretic may 
be given. The following combination for a child not 
under 10 years old is efficient: 

Gm. or C.c. 

fy Acetphenetidini 1 1 

Phenylis salicylatis 1| aa gr. xv 

M. et fac chartulas v. 

Sig. : A powder every three hours, if needed. 

Later, if the temperature is high, tepid sponging is 
sufficient, but generally, with the ordinary low tem- 
perature of diphtheria, hot sponging for cleanliness 
and to increase the activity of the skin, and to remove 
the perspiration, should be done once or twice daily. 

As suggested . above, every patient with diphtheria 
should receive iron, either the tincture of iron chlorid. 
a few drops in fresh lemonade, or a 3-grain tablet of 
eisenzucker, three times a day, or 0.10^ gm. (1% 
grains) of reduced iron, in capsule, three times a day. 
If there is a tendency for the throat or nose to bleed, 
it can do no harm to add lime water to the diet, and it 
may be of value. 



THE HEART IN DIPHTHERIA 101 

On account of the nervous depression caused by the 
toxins of the Klebs-Loeffler bacillus, a small dose of 
strychnin, not exactly as a cardiac stimulant, but more 
as a nervous stimulant, is advisable, provided the con- 
dition of the patient seems to require it. For a child 
10 years old, 1/60 grain of strychnin sulphate, once in 
six hours, is generally a sufficient dose. If the child 
is made nervous by strychnin, it should certainly be 
withheld. A little coffee or tea may be given a child, 
as a medicine for the action of the caffein, and is of 
value. 

F. Care of the Heart. — Although it was long con- 
sidered that heart failure in diphtheria was due to 
vasomotor paralysis, or to action on the vasomotor 
center, it has been shown by Porter and Pratt that 
such is probably not the case: that heart failure is 
probably due to the action of the toxins on the heart 
itself. Dr. F. W. White of Boston long ago showed 
that the heart was frequently affected more or less 
seriously in diphtheria. White also quotes many other 
authorities showing that myocarditis is not an infre- 
quent complication, that valvular disease may occur 
from diphtheria, and that even a chronic myocarditis 
may persist, or a valvular lesion may continue for 
months or even years, or for life. The mitral valve 
is the one most frequently diseased, and if a lesion is 
caused, it is generally insufficiency. About 60 per 
cent. of the patients with diphtheria show an irregular 
pulse, and the younger the patient, the more liable he 
is to have this heart irregularity. It may occur even 
in mild cases. The murmur at the apex is doubtless 
due to a relative insufficiency of the mitral valve, 
because of slight dilatation of the left ventricle. In 
this investigation, necropsies showed that endocardi- 
tis and pericarditis are not extremely rare complica- 
tions in diphtheria. 

Clinically, the gallop rhythm, with or without vomit- 
ing and epigastric pain and tenderness, is a bad symp- 
tom in diphtheria. This gallop rhythm of the heart 
is very serious, and if accompanied by vomiting, the 
prognosis is very bad. Hume and Clegg, after an 
investigation of 573 cases of diphtheria, declare that 
any form of arrhythmia of the heart (except sinus 



102 DIPHTHERIA 

arrhythmia) in diphtheria indicates that the heart mus- 
cle or nerves are pathologically disturbed. This may 
occur even when the diphtheria is apparently mild. 

After a patient is apparently well from diphtheria, 
if he has been severely ill, and especially if the case 
has been neglected and a large amount of toxins have 
been absorbed, cardiac failure may occur any time 
from the second to the fifth week. Symptoms of late 
cardiac weakness are often a slow, weak pulse. Such 
hearts, however, become rapid on the least exertion. 
Such patients are often very pale, and there are liable 
to be more or less gastro-intestinal disturbances. 

There can be no question that the effects on the heart 
in diphtheria are due to the Klebs-Loeffler bacillus 
toxins; consequently, if antitoxin in sufficient dose is 
given early, the toxic effect on the heart will probably 
rarely occur. Consequently, cardiac deaths in diph- 
theria will be less frequent with the early proper 
administration of antitoxin. 

The most important treatment of cardiac complica- 
tion is rest, and prolonged rest. A patient who has 
shown cardiac inflammation of any kind, or cardiac 
irritation during diphtheria, should have a prolonged 
rest in bed and a very slow convalescence. The small 
dose of strychnin suggested above as a nerve stimulant 
is probably sufficient. If the heart is very rapid, it 
may be unwise to give even this small dose. Larger 
doses do not seem to raise the blood pressure during 
illness, and strychnin in large doses as a cardiac tonic, 
in prolonged weakness, is not so successful as has been 
thought. In an apparently acute failure, a fair-sized 
dose, 1/40 grain for a child 10 years old, may be given 
hypodermically ; but to persist in large doses of strych- 
nin is inadvisable. Digitalis is not indicated, and alco- 
hol should not be given. Caffein and camphor may be 
worth while ; but the main thing is absolute rest, small 
amounts of food, and the least possible disturbance for 
bathing, feeding, defecation and urination, and no 
prostrating purgatives. 

G. After Rest. — A patient who has recovered from 
diphtheria, however mild it may have been, should 
have, for the first two weeks, at least, a carefully 
watched convalescence. Strenuous exercise should be 



LARYNGEAL DIPHTHERIA 103 

avoided, and the heart should be carefully examined 
before the patient is allowed to return to his usual 
work, school, or play. 

H. Paralysis. — With the early injection of a suffi- 
cient dose of antitoxin, diphtheria paralysis will 
become less and less frequent. The paralysis of the 
soft palate, which used to be so frequent, is already 
becoming infrequent. This paralysis occurs early, 
between ten and twenty days from- the beginning of 
the illness. The treatment consists of tonics, small 
doses of strychnin, the best of nutrition, fresh air, 
sunlight, rest, and prolonged convalescence. The gen- 
eral paralyses, which are now rarely seen, were more 
serious, and occurred later. They are slow in recov- 
ery, and besides general treatment, require massage 
and electricity. 

/. Diseased Tonsils. — Quite probably diseased ton- 
sils cause a susceptibility to diphtheria, as they cer- 
tainly do to follicular tonsillitis. After complete 
recovery from a diphtheria attack, when the general 
condition is perfect, and the heart is in good condition, 
operations should remove all tonsils that show disease. 

LARYNGEAL DIPHTHERIA 

Membranous croup is laryngeal diphtheria, and as 
soon as the diagnosis can be made that there is exu- 
date in the larynx or laryngeal region, antitoxin should 
be given in large dose, without waiting for a decision 
from the laboratory that the Klebs-Loeffler bacillus is 
present. The only safe place for a patient with 
laryngeal diphtheria is a contagious disease hospital, 
where expert skill in intubation and, if necessary, in 
tracheotomy can be quickly obtained. The main dan- 
ger from diphtheria in this location is suffocation. 

The toxemia is not great, and the absorption is much 
less than in nasal, nasopharyngeal, or even in tonsillar 
diphtheria. 

The best of nutrition is important, as exhaustion 
from labored breathing is likely to occur. The atmos- 
phere of the room is better moist, on acount of the 
membrane becoming dry and causing more obstruc- 
tion before it loosens and is coughed up. Just how 
much local steaming of the throat, or inhalation of 



104 SEPTIC SORE THROAT 

various medicated solutions should be given, is to be 
decided by the individual physician. The main advan- 
tage is doubtless from the vapor of water. 

The main requirements to be remembered in laryn- 
geal diphtheria are the administration of .an immediate 
large dose of antitoxin ; intubation by a skilled operator 
as soon as indicated ; a trained nurse skilled in intuba- 
tion cases, if such can be obtained ; the ability to recall 
quickly the physician who intubated if the tube is 
coughed up; the immediate removal by the nurse of 
the intubation tube if it plugs up, and the quick per- 
formance of tracheotomy by the surgeon, if such a 
measure is needed. 

SEPTIC SORE THROAT 

For some years there have been reported epidemics 
of septic sore throat, some of which have been dis- 
tinctly traced to infected milk, and all of which prob- 
ably develop from that source, or by transmission 
directly from active cases. The germs found in the 
inflamed udders, in the raw milk, and in the throats of 
those infected are the same, namely, the Streptococcus 
pyogenes. ■ 

The clinical symptoms have been the same in all of 
these epidemics. The throats generally show intense 
hyperemia without a grayish exudate. The cervical 
lymph glands enlarge, and may suppurate; there is 
extreme prostration, and a tendency to relapse. The 
complications are inflammation of the middle ear, 
abscess around or about the tonsils, and erysipelas 
or other skin eruptions. The most dangerous and fatal 
complication is peritonitis, and there may be fatal septi- 
cemia, with localization in the lungs. Endocarditis, 
myocarditis, arthritis, and nephritis may occur as 
complications in this septic process. 

Means of prevention of septic sore throat in epi- 
demics must include a more frequent bacteriologic 
examination of the udders of cows and of the throats 
of those who handle raw milk. Pasteurization of milk 
prevents the germs from causing infection. 

The treatment of septic sore throat is not different 
from that of follicular tonsillitis, namely, application of 
dilute hydrogen peroxid solutions 1 :4, immediate sub- 



TREATMENT OF MEASLES 105 

sequent washings with mild alkaline cleansing solu- 
tions, and the local application of a weak iodin 
solution, as Lugol's solution (too strong iodin prepara- 
tions might increase the swelling and hyperemia of 
the throat). 

On account of the prostration, the patient should 
receive plenty of nutriment. The bowels should be 
moved daily. Pain should be stopped, if it is trouble- 
some, by codein or morphin, if deemed advisable. 
High temperature should be treated as seems best, and 
the complications combated as they occur. Infection 
of others is prevented by the same methods as those 
described for diphtheria. After recovery the removal 
of infected tonsils should be considered. 

RUBELLA (GERMAN MEASLES) 

This is a highly contagious disease, most frequently 
affecting children and youth. It generally occurs in 
epidemics, but a considerable number of persons 
exposed to the disease do not acquire it. While the 
germ has not been discovered, and though it is not 
known just how it is transmitted, the probability is 
that the secretions of the nose and throat are the 
means of spreading the infection. It is doubtful if 
the eruption or the desquamating epithelium carries 
the contagium. The stage of incubation is apparently 
long, averaging perhaps from about ten days to two 
weeks. The stage of invasion is rarely seen, as when 
it is first realized that the patient is ill, the eruption 
is present. The eruption is a maculopapular one, 
reddish, and rarely confluent. The papules are less 
raised than in measles; in fact, many points of erup- 
tion are purely macules. The color is brighter than 
that of measles. It occurs first on the chest and face,- 
and then gradually spreads over the body, during 
the first twenty-four hours. Questioning of the per- 
son attacked often shows that there were slight rigors 
and some backache or headache or feelings of indis- 
position. The temperature is generally slight, rarely 
above 100 F. An occipital adenitis, with swelling of 
the post-cervical glands, is a very frequent accompani- 
ment of the disease. 



106 CHICKEN-POX 

Complications are rare. Although the patient should 
be confined to the house, the infection is simple, and 
there are not likely to be complications or sequelae. 

This disease requires, ordinarily, no radical treat- 
ment. Simple cathartics should be given, the diet 
reduced, and the patient kept indoors until the eruption 
has disappeared. If the throat is irritated, an alkaline 
gargle should be used. Boric acid, 2 per cent, to 4 per 
cent., or Dobell's solution, one-fourth strength, may be 
used for this purpose. The usual simple methods of 
preventing the infection of others should be carried 
out. It is well to isolate the patient from other chil- 
dren in the family for at least three weeks. 

The disease should be made reportable, as it is so 
often confused with regular measles, and, rarely, has 
been confused with mild scarlet fever. It is more 
likely to be confounded with various kinds of intes- 
tinal or food poisonings that cause eruption. 

CHICKEN-POX; VARICELLA 

This simple, acute, contagious disease, generally 
very mild, and rarely requiring any medication or 
treatment, need not be mentioned here except that it 
is frequently confused with smallpox. 

In chicken-pox: The incubation period is at least 
two weeks. There is no definite history of a pre- 
vious attack of this disease. A history of successful 
vaccination within a few years, or a definite history 
of a previous smallpox causes presumption that the 
disease is chicken-pox. There is usually no history 
of a stage of illness before the eruptive stage. The 
eruption appears in the first twenty-four hours of the 
disease, beginning on the back, chest or face, and is 
most profuse on parts of the skin covered by cloth- 
ing. The eruption appears in successive crops on 
successive or alternate days, so that various stages of 
the lesions may be present at one time. The lesions 
are round and oval, and the margins are not crenated. 
The eruption passes through the following stages : 
1. Macules lasting a few hours. 2. Soft, superficial 
papules lasting a few hours. 3. Clear, thin-walled, 
tense vesicles each lasting a few hours (these vesicles 
may be readily broken and appear cupped or pitted, 
and the weeping vesicle then quickly becomes crusted). 



MUMPS 107 

4. The crusts, lasting a shorter or longer time, depend- 
ing on the treatment (each crop completes its cycle 
from macule to crust in from two to four days). 

5. Pitting may occur, but the pits are few, superficial, 
and often oval. 

It is essential that chicken-pox cases should be early 
diagnosed, and that the patient should be isolated. A 
laxative should be given; the diet should be simple 
and without meat; warm baths, and powder to pre- 
vent itching, represent the only treatment generally 
required. Older patients should be cautioned, and 
children should be prevented from picking open the 
vesicles that occur on the face, thus preventing pit- 
ting. Young children should wear celluloid mittens. 
To control the itching of the skin it may be dabbed 
with a weak solution of bicarbonate of soda, one dram 
to the pint or four grams to 500 c.c. 

MUMPS 

This is a highly infectious disease, with a long period 
of incubation, from two to three weeks. The causative 
organism is not known, though a diplococcus or strep- 
tococcus has been found by Laveran, Catrin, Herb and 
Rosenow. Wollstein found that the saliva of those 
infected contains a filterable infective agent. The virus 
is most readily detected in the saliva during the first 
three days of the disease, less readily on the sixth day 
and not at all after the ninth day. This has some bear- 
ing on the question of infectivity and the length of 
isolation period for mumps patients. There is more or 
less mumps always present in most cities, and there 
are likely to be epidemics of it in certain seasons of 
the year, more particularly, perhaps, in the spring and 
fall. Children and youths, especially boys and young 
men, are the most susceptible to it. Infants and adults 
are less likely to have it because they have been ren- 
dered immune by unrecognized mild attacks in 
childhood. 

While the typical localization of this infection is in 
one or both parotid glands, the submaxillary glands 
may be coincidently involved, or may be the only 
glands involved. As simple and harmless as this dis- 
ease generally is, it may cause very high temperature, 
sudden cardiac failure, and frequently in young boys 



108 TREATMENT OF MUMPS 

and male adults a complication, or metastasis, of 
orchitis, which is always serious. In girls the mam- 
mary glands or the ovaries may show metastatic 
inflammation. 

A patient with the disease should generally be 
isolated, and the attack will often be milder if the 
patient remains in bed. Of course, an infected child, 
even though very mildly sick, is immediately sent home 
from school. On the other hand, doubtless not a few 
children with very mild cases are unwittingly allowed 
to remain at school. 

TREATMENT 

The disease is so mild that it may not require 
special treatment. Pain in the infected glands is 
rarely severe, and is modified by dry warmth or simple 
absorbent-cotton applications, and by any oily appli- 
cation, the latter to relax the tension of the skin over 
the swollen gland. For this purpose olive oil may 
be used, or petrolatum, or an ointment may be made 
with 10 per cent, methyl salicylate in petrolatum. It 
is inadvisable to use ice or cold applications to the 
parotid glands in mumps. 

The diet should be mild, the bowels kept free, and 
in simple cases medicinal treatment is not needed. If 
the fever is very high, one or two doses of antipyrin 
or acetanilid may be given, with the knowledge that 
cardiac depression readily occurs in this disease. Hot 
drinks, as hoMemonade or tea, with perhaps a Dover's 
powder for its physiologic action in dilating the 
peripheral blood-vessels and promoting perspiration, 
is a satisfactory method of reducing the temperature. 
Tepid sponging may be of benefit, and hot sponging 
should be given the patient daily if he is too ill for a 
hot bath. 

If a testicle is affected, the lesion is generally an 
orchitis, or it may be an epididymitis. Warm, moist 
applications often relieve pain ; but if the testicles are 
kept elevated and surrounded by absorbent cotton, and 
if some oil or fat, such as petrolatum, is applied, the 
inflammation will probably, go away as rapidly as by 
any other treatment. Strapping is inadvisable in this 
complication. Massage, or rubbing in of any ointment 
or other preparation in this kind of orchitis, or any 



EPIDEMIC MENINGITIS 109 

such treatment of the parotid glands, is inadvisable in 
mumps. Ichthyol applications in from 10 to 20 per 
cent, strength either in petrolatum, in olive oil, or in 
glycerin and water, have been largely used locally in 
this inflammation. The less these inflamed glands are 
manipulated the better. 

If the mammary gland becomes metastatically 
inflamed, the treatment is about the same as that for 
the parotid. If it is decided that the ovary is inflamed, 
but little can be done, except absolute rest and the 
administration of a sedative, if there is pain. If there 
is much pain from any of these inflamed glands, mor- 
phin or codein may be advisable, if it seems unwise to 
give a coal-tar analgesic. 

The period of isolation should be about twenty-one 
days. 

EPIDEMIC MENINGITIS 

This disease occurs in epidemic and sporadic forms. 
In the latter case it is often difficult of diagnosis. 
While young children and young adults are most often 
attacked, it occurs not infrequently in camps, or in 
other groups of closely associated persons. The spor- 
adic form is always more or less present in most cities. 
Epidemics appear, both in this country and in Europe, 
most frequently in the winter and spring months, and 
the greatest number of sporadic as well as epidemic 
cases occur during March, April and May. 

The cause of epidemic cerebrospinal meningitis is 
the Diplococcus intracellularis meningitidis, also called 
meningococcus, which was first described by Weichsel- 
baum, in 1887. These cocci are found in the spinal 
fluid. It has been found that a second lumbar punc- 
ture made a few hours after the first or a drawing of 
the spinal fluid so as to get some of the fluid from the 
brain more frequently yields the organisms than the 
first fluid coming from the puncture needle. This indi- 
cates again that the organisms may reach the brain 
directly from the nasal passages before reaching the 
spinal cord. In appearance the organisms are very 
much like gonococci, and lie in pairs ether in or near 
the leukocytes. These germs are also found in the 
secretions of the nose and nasopharynx. The menin- 
gococcus is of low vitality and is readily killed by sun- 



110 EPIDEMIC MENINGITIS 

shine, drying and by freezing; therefore, with ordinary 
precautions the danger of contagion is slight. As in so 
many other diseases, carriers of this germ have been 
found, and they probably play a considerable part in 
the spread of epidemics and in the occurrence of spor- 
adic cases. 

Dopter was the first to classify meningococci into 
distinct types. Today four different types are com- 
monly recognized. It was found as a result of experi- 
ence in the war that treatment with serum against one 
type was not efficient against others. As a result 
efforts should be made if possible to have type deter- 
mination made by a reliable laboratory as early as pos- 
sible in cases of this disease. 

From these facts meningococcus cerebrospinal men- 
ingitis should be made a reportable disease, whether 
occurring in sporadic or epidemic form, and carriers 
should be sought, and when discovered, isolated and 
treated. 

In the first place, it may be noted that rarely has the 
disease attacked an individual more than once. In the 
second place, carriers have become more or less 
immune, but it is self-evident that, having been dis- 
covered, although close contact is needed, and though 
the germ is not sturdy and is readily killed after leav- 
ing the body, they must be isolated and treated. There- 
fore, the persons immediately surrounding a case of 
meningococcic meningitis should have the secretions 
of the nose and nasopharynx examined for this germ. 
It has not been shown just what local treatment of the 
nose and throat of these individuals is advisable, but 
antiseptic sprays, swabbings and gargles are certainly 
indicated. 

Vaccinations, with dead meningococci, of children 
who have been directly exposed to the disease, and of 
the nurse or other persons, who must care for cerebro- 
spinal fever patients has been suggested in preventing 
the spread of the disease. It has been suggested that 
a moderate amount of immunity would be sufficient to 
prevent this particular infection. How long such 
immunity would last is not known. Vaccination 
with this germ causes a febrile reaction, with leukocy- 
tosis. Meningococcus vaccines are now prepared, and 
can be readily obtained. 



TREATMENT OF MENINGITIS 111 

The symptomatology need not be considered here. 
It should be remembered, however, that the disease 
may be systemic with an eruption, as witnessed Dy 
its old name, "spotted fever." 

TREATMENT 

During the war Herrick and others discovered many 
cases of meningitis which were definitely of the sys- 
temic type. The symptoms were a petechial rash, 
arthritic pains and complications such as panophthal- 
mitis, endocarditis, pneumonia, pleurisy and orchitis. 
These findings indicated a wide dissemination of the 
organism in the blood stream. In such cases intra- 
venous serum therapy accompanying the intraspinal 
treatment was of marked benefit. Massive doses of 
antimeningococcus serum were introduced in this way. 
The patient was desensitized by the injection of lex. 
of serum subcutaneously. One hour later from 80 to 
150 c.c. of serum were given by vein, the first 15 c.c. at 
the rate of 1 c.c. per minute. The remainder was 
allowed to flow more rapidly. In severe cases this 
dosage was repeated every eight to twelve hours and 
in mild cases every twenty-four hours until the symp- 
toms subsided. The intraspinal therapy is not to be 
neglected. 

Dopter believes that polyvalent serum should be used 
only until type determination is made when the mono- 
valent serum should be employed. With these intra- 
venous or intramuscular injections should be combined. 
If the fluid taken from the spinal canal is cloudy, 
immediately inject antimeningitis serum, warmed to 
the body temperature. Inject slowly. The dose for 
an adult is from 20 to 40 ex., and for infants and 
children from 3 to 20 c.c, the amount largely depend- 
ing on the quantity of fluid withdrawn. The dose 
should usually be from 5 to 10 c.c. less than the amount 
of fluid withdrawn. Occasionally in true menin- 
gococci meningitis no fluid flows from the canal in 
spinal puncture, so-called dry tap. In such cases a 
small amount of the antiserum may be injected, with 
careful watching of the patient to note changes in 
pressure as determined by the character of the pulse 
and respiration. In severe cases the antiserum is 



112 EPIDEMIC MENINGITIS 

injected every twelve hours until there is improvement. 
In moderate and mild cases the injection is repeated 
once a day for four days. The bacteriologic findings 
of the fluid withdrawn at the last injection, and the 
condition of the patient, determines whether the anti- 
serum should be longer given. Usually from four to 
six injections are necessary, but more are given if 
required. On successive punctures and injections the 
patient is turned first on one side and then on the 
other, which insures the emptying of the lateral 
ventricles in rotation. In other words, a patient who 
lies on his right side for one puncture will be placed 
on his left for the next. 

In some instances following injection of .serum the 
patient may go immediately into a condition of shock, 
with the respiration shallow, the face pale, and the 
pulse rapid and thready. The needle is immediately 
lowered and the fluid allowed to flow from the canal. 
Artificial respiration should be resorted to if the 
breathing has ceased, and hypodermic stimulation of 
the heart should be given. Large doses of epinephrin 
may be given intramuscularly. This condition of shock 
does not occur frequently with the smaller doses that 
are now administered. 

When the condition of the patient is such that 
intraspinal injection of serum cannot be made Her- 
rick and others have suggested large intravenous injec- 
tions, followed by drainage of the spinal fluid. Dopter 
has pointed out that there may be obstruction in the 
spinal canal which prevents passage of the serum 
throughout and that in such cases injection at other 
points than in the lumbar region may be advisable. He 
also suggests that possible beneficial effects may be 
secured by the production of fixation abscess through 
the subcutaneous injection of 2 c.c. of turpentine. He 
also suggests the use of from 100 to 500 million menin- 
gococci killed by heat at 55 C. In some of his cases 
marked benefit followed this treatment when the 
patients did not respond to the serum treatment. 

Cerebrospinal fever demands the best hygienic sur- 
roundings obtainable, and a quiet, cool, darkened room, 
as in any meningitis. The bowels should be thoroughly 
moved in the beginning, and then, daily, or every other 
day, the patient should receive a laxative, if needed. 



SYMPTOMS OF MENINGITIS 113 

As the vomiting is reflex, stomach sedatives are of 
no avail. As the central condition is improved or the 
patient becomes more stuporous, the vomiting will 
cease. Food in the early stages should not be pushed, 
as there is great repugnance to it. Plenty of water, and 
later simple cereal gruels and milk should be the early 
diet. The subsequent diet should depend on the height 
of the fever and the ability of the patient to digest. In 
the stage of convalescence food should be pushed, if it 
is well digested. Through the active illness, starches 
should be given to prevent acidemia. If the pain is 
sufficient to require sedatives, much food should not 
be given, as it will not well digest. 

A most important symptom of this disease is likely 
to be pain, and there is no excuse for allowing a 
patient, because it is a young child, to suffer pain. 
Morphin or codein represent the most efficient and the 
safe narcotics, the dose, of course, being regulated 
according to the age of the patient and the effect. 
Generally it is better to administer a very small dose 
hypodermically than a large dose by the mouth ; the 
action of the whole dose is obtained, and there is no 
doubt as to whether or not it is absorbed. Ergot given 
in aseptic form, intramuscularly, not only seems to act 
as a sedative to the nervous system and possibly dimin- 
ishes congestion, but it certainly prolongs the action of 
any dose of a narcotic. Less morphin, codein or other 
narcotic will be required to stop pain and cause rest if 
ergot is coincidently given. If the blood pressure is 
low, this is another indication for the administration 
of ergot. Generally, if the blood pressure is high, 
ergot should not be given. 

Local applications of cold and ice to the head (the 
hair being cut short) and to the spine, may inhibit the 
inflammation, and sometimes seem to be of great value. 
At other times these cold applications increase the 
pain. This is especially true if the temperature 
is low. Exactly what these cold applications do 
to the blood vessels of the parts inflamed is a ques- 
tion that has not been determined. Cold sponging of 
the body is hardly advisable, as it tends to increase 
the internal congestion. Theoretically, it would seem 
more sensible, and practically it is often better to use 



114 POLIOMYELITIS 

hot applications, as hot sponging, and even hot baths 
have been advised for very young children, to relieve 
the congestion of the central nervous system. 

Painful joints may be wrapped in cotton and kept 
warm, much as is done in rheumatism. Conjunctivitis 
should be treated with a boric acid wash. The throat 
and nose should be cleansed with saline sprays or mild 
antiseptic gargles. 

There would seem to be no excuse for the adminis- 
tration of quinin, strychnin, caffein, or any other cere- 
bral stimulant. It would also seem inadvisable to 
administer alcohol in any form. If the blood pressure 
is high, hot sponging, small doses of nitroglycerin and 
more brisk catharsis are indicated. 

The patient should remain in bed for at least a week 
after the cessation of the fever, and convalescence 
should be slow, and the return to activity should be 
delayed. During convalescence it is well to administer 
small doses of sodium iodid, as iodin seems to be effi- 
cient in aiding the absorption of exudates. Iron and 
other tonics may be indicated. 

Stiffening of the muscles and joints may require 
massage, and, if there are any adhesions in the joints, 
an orthopedist should be consulted as to whether pas- 
sive movements or forcible breaking up of these adhe- 
sions under an anesthetic is advisable. 

The frequency with which mental deterioration 
occurs can only be determined by a long, careful study 
of many cases. Cerebral degenerations and disturb- 
ances may develop after many years and yet appar- 
ently have been caused by this disease. 

The various complications that may occur have 
already been mentioned, and their treatment would be 
that usual for the localized inflammation modified by 
the general condition of the patient from the cerebro- 
spinal fever. 

ACUTE ANTERIOR POLIOMYELITIS 

DEFINITION 

It would seem that Flexner's criticism of the long- 
used names for this disease is justified, because the 
infection may be present and yet there be no real 
inflammation of the cord justifying the names of 



EPIDEMIOLOGY OF POLIOMYELITIS 115 

anterior poliomyelitis or infantile paralysis. How- 
ever, whatever the name, it should be considered an 
infective, communicable disease that attacks the nose 
and throat, and causes the usual general symptoms 
of infection not unlike influenza; that it is likely to, 
but by no means always does, cause an inflammation 
of the central nervous system; and that it frequently, 
but by no means always, causes paralysis. When 
paralysis is caused, it is distinctive as being almost 
entirely a motor paralysis. 

EPIDEMIOLOGY 

Although this disease is distinctly epidemic, it more 
or less constantly occurs sporadically. It has occurred 
in this country in epidemic form for years, but has 
become more frequent since 1906, and many epidemics 
have been reported since that date. The largest and 
most fatal epidemic is the one of the summer of 1916, 
when 27,000 cases occurred in the United States, most 
of them in New York and the adjoining states. 

Epidemic poliomyelitis seems to be self-limited, the 
disease dying out in a certain number of weeks. These 
epidemics occur most frequently in the warm months, 
June, July, August and September, but just what 
causes the disease to stop has not been determined. 
Although cold weather is not apparently conducive to 
the growth of the germ of the disease, still sporadic 
cases may occur in any month of the year. In New 
York City the epidemic of 1916 began in June, and 
practically ended in October. A winter epidemic 
recently occurred in West .Virginia. There is no ques- 
tion that the spread of the disease is stopped by proper 
quarantine. 

Children under five years of age are most suscept- 
ible to the disease, but no age is exempt. About 10 
per cent, of a population is ordinarily composed of 
children under this age, but perhaps only an average 
of one in every hundred of these children acquire the 
disease in any one epidemic. In other words, a large 
number of all children, as well as most adults, are 
immune, or are not susceptible to this germ. 

In the 1916 epidemic in New York City 1.6 persons 
in every thousand of the population were attacked, as 
against 2.4 in the rural districts; and in New York 



116 POLIOMYELITIS 

City 80 per cent, of those attacked were under five 
years of age. (Matthias Nicoll, Jr., Amer. Jour. Dis. 
Child., Aug., 1917, p. 69). 

Just what predisposes to a new epidemic cannot be 
determined. The disease is always sporadically with 
us. The germs of other epidemic diseases may pre- 
dispose to the development of this disease. 

Unhygienic surroundings do not precipitate or pro- 
mote this infection. The most perfectly housed and 
cared for child may acquire the disease, while the 
most neglected, ill-conditioned and unwholesomely 
housed child may escape it. 

FATALITY 

The disease is most fatal in young infants, and is 
more fatal to boys than to girls. Epidemics show an 
average of a 10 per cent, death rate, but the New 
York City epidemic of 1916 had a death rate of 27.2 
in every 100 cases, i. e., more than one-fourth of the 
patients died. Paralysis of the respiratory muscles or 
of the respiratory center is the most common cause 
of death. 

contagion 

It seems to be proved beyond question that the dis- 
ease is transmitted by direct or indirect contact, and 
principally by contamination with the infected secre- 
tions of the nose, mouth, and throat. Whether infec- 
tion occurs by direct transmission of the infected mu- 
cus by kissing, or by eating or drinking out of common 
receptacles, or by inhaling droplets which have been 
coughed or sneezed into the atmosphere around a 
patient, or by inhaling infected dust, the fact remains 
that it is transmitted from person to person. While 
the virus of the infection has been found in the feces, 
it is not known that it can long live in this environ- 
ment. Secretions from inflamed eyes and ears of these 
patients may transmit the disease. 

Though the feet of flies or their mouths may carry 
the infection and plant it where contact can occur, 
neither they nor any other insect have been shown to 
harbor this infection or to transmit it to man. No 
domestic animal has been shown to have or to suffer 



CONTAGION IN POLIOMYELITIS 117 

i 

from this disease, although the paralytic symptoms 
of the distemper of dogs and horses have suggested 
the possibility of a relationship. 

To eradicate the disease, isolation, screening, and 
strict quarantine of the patient are absolutely essen- 
tial. The nurse must sterilize all clothing and utensils 
used by the patient. All nose, throat, and bronchial 
secretions should be caught on gauze, if possible, and 
burned. Feces and urine should be collected in anti- 
septic solutions, or the diapers should be boiled. The 
nurse should not come in close contact with others, 
especially children, and should not prepare food for 
anyone other than herself and the patient. Though 
she may be immune, she may be a carrier; and we 
must recognize that this germ may be carried, as well 
as is the diphtheria germ, although the carrier may not 
have had the disease as far as is known. 

In all epidemics a large number of unrecognized 
and "missed" cases undoubtedly occur, and account 
in part for the spread of the disease. 

Probably the most active period for infection to 
occur is during the first week of the disease, but just 
how many days longer a patient could give the dis- 
ease is not known ; a quarantine of three weeks would 
seem to be protective to the community. A child or 
youth known to have been exposed to poliomyelitis 
should be isolated and under suspicion for two weeks. 

The incubation is from three or four days to two 
weeks ; perhaps it is generally about one week. How 
long a carrier continues to be a carrier is not posi- 
tively known. Swedish observers have championed the 
view that chronic carriage of the virus of poliomyelitis 
is common. However, painstaking critical and experi- 
mental studies by Flexner and Amoss of the Rockefel- 
ler Institute are not in accord with this conclusion. 
Their deductions are to the effect that the virus is 
regularly present in the nasopharynx in cases of polio- 
myelitis in the first days of illness, and especially in 
fatal cases ; that it diminishes relatively quickly as the 
disease progresses, except in rare instances; and that 
it is unusual for a carrier state to be developed. Hence 
the period of greatest infectivity of patients would 
appear to be early in the disease, which is probably the 
time at which communication of the virus from person 



118 POLIOMYELITIS 

to person takes place. Therefore, preventive measures 
should unquestionably be centered on the actual 
patients and particularly early in the disease. How 
frequently a cured patient becomes a carrier is not 
known. Theoretically a patient cured of an acute 
attack of this disease has developed enough antibodies 
to overcome the infective agent in the nose and throat 
as well as in the cerebrospinal canal. 

The germ or virus is not killed by ordinary drying ; 
hence dust may carry this potent poison. 

The majority of adults and most children over ten 
years of age, and a goodly number under ten years 
of age, are immune to this disease. How generally 
this immunity is natural or inborn, and how often 
such immunity has been acquired by abortive, undiag- 
nosed attacks of this disease, cannot be determined. 
Recovered patients and inoculated and recovered 
monkeys have in their blood antibodies against this 
infection. The blood serum of normal adults shows 
such antibodies, though not of equal amount or of 
equal effectiveness to the blood serum of one who 
has had the disease, even many years before. 

THE ETIOLOGIC ORGANISM OF POLIOMYELITIS 

An interesting contention has arisen regarding the 
organism of poliomyelitis. In 1913, Flexner and 
Noguchi reported the finding of a micro-organism 
which they described under the term "globoid bodies" 
and which they stated seemed to bear an etiologic 
relationship to the disease. More recently, in connec- 
tion with the epidemic of 1916, Mathers, Nuzum and 
Herzog, and Rosenow, Towne and Wheeler described 
an organism or organisms of a coccal nature and sub- 
mitted evidence to show an etiologic relationship to 
poliomyelitis. The publication of this work appar- 
ently prompted Amoss of the Rockefeller Institute to 
extend that on the globoid bodies. He points out, 
moreover, that the globoid bodies have been made to 
fulfil Koch's law. It should be pointed out here that 
the coccus which has been mentioned, when grown in 
the media in which the globoid bodies are grown, 
assumes globoid forms ; like the infectious material in 
poliomyelitic virus, it is filterable and resists the action 



ETIOLOGY OF POLIOMYELITIS 119 

of glycerin. Bull, another worker in the Rockefeller 
Institute, insists that the organism reported by 
Mathers, Rosenow, Towne and Wheeler, and by 
Nuzum and Herzog is a streptococcus. He points out 
that the findings of these authors conflict in several 
respects with those of previous investigators in this 
country and abroad, all of which tend to exclude 
bacteria as the inciting agents of epidemic poliomyelitis. 

Rosenow and Towne conclude from their most recent 
studies that the small globoid micro-organism which 
Flexner, Noguchi and their co-workers have consid- 
ered to be the cause of experimental poliomyelitis has 
always, in their experience, been the result of the 
breaking down of large diplococci, which have been 
isolated from the central nervous tissues of each 
monkey infected with experimental poliomyelitis. 
These organisms have not been isolated from other 
tissues except lymph glands of poliomyelitic monkeys, 
nor from any tissue of normal, monkeys. The mechan- 
ism by which the large forms become small has been 
demonstrated. 

Obviously the subject demands further investigation 
and confirmation. Certainly, if the work of Rosenow 
and Towne is confirmed, the differences in the asser- 
tions of the various experimenters will be quite satis- 
factorily explained. The fact remains that a very 
interesting coccus has been found in the brain and 
spinal cord in patients that have died from poliomy- 
elitis, but its relation to the disease is not yet deter- 
mined. It may be a secondary invader or it may have 
a larger and more direct significance. In any event 
its discovery appears to be a distinct contribution to the 
bacteriology of the disease or diseases which have been 
called poliomyelitis. 

CEREBROSPINAL FLUID 

The cerebrospinal fluid shows early in this disease 
an increase in the number of cells, from 30 to several 
hundred per cubic millimeter. Eighty per cent, or 
more are mononuclears. The globulin content is 
increased, and the presence of dextrose is demon- 
strated by the reduction of Fehling's solution. Mild 
and even abortive cases may show the same spinal 



120 POLIOMYELITIS 

fluid changes. "The blood in the pre-paralytic stage 
does not show a total leucocytic count in excess of 
what might be considered normal, but as the infec- 
tion progresses, there is a constant and marked 
leucocytosis, with an increase of 10 to 15 per cent, 
of polymorphnuclears, and a decrease of 15 to 20 per 
cent, of lymphocytes." Meningism, syphilis and either 
tuberculosis or purulent meningitis may be confused 
with the early stages of poliomyelitis. 

That the virus of poliomyelitis travels along the 
nerve, trunks as does the virus of hydrophobia, is the 
generally accepted view, and seems to be proved by 
experiment. 

EARLY SYMPTOMS 

The onset of the disease is usually sudden, without 
prodromal symptoms, with a more or less sharp rise 
of fever. The fever may or may not become high, 
but the pulse and respirations are likely to be much 
increased. Another constant symptom is pain, more 
especially in the head and back of the neck, and there 
may be pain on movement of any part of the body. 
There is especially likely to be pain down the spine 
and in the legs ; there may be some stiffening of the 
spine and the back of the neck. While the patient 
may be drowsy, the brain is likely to be clear. Instead 
of drowsiness the patient may be irritable. The 
pharynx is generally red, and the tonsils are red. 
There may be spots or even membrane on the tonsils. 
The eyes may be congested. 

These symptoms occurring during an epidemic of 
poliomyelitis should cause this disease to be suspected, 
and spinal puncture should be made for a positive 
diagnosis; 

Though most patients are constipated, there may be 
diarrhea, and there may be vomiting. Gastrointestinal 
symptoms occurring in an epidemic of poliomyelitis, 
with an unusual amount of muscle, back, and head 
pains, should also cause a suspicion of this disease, and 
spinal puncture should be made. 

In many instances, the fever of the first day or 
two is followed by a remission, and then a second 
attack of fever, and later paralysis ; or paralysis may 
occur on the first day, depending upon the amount of 



DIAGNOSIS OF POLIOMYELITIS 121 

cerebrospinal inflammation. An older patient may 
complain of dizziness. There may be diminished 
patellar reflexes, although they are likely to be at first 
increased. There may be bladder paresis and reten- 
tion. There may be all kinds of hyperesthesia and 
vasomotor disturbances, as flushing and blanching of 
the skin of different parts of the body. Herpetic 
eruptions are not infrequent. Kernig's sign is often 
present. Profuse sweating may occur, and there may 
be eruptions on the skin of varying types, mostly 
erythematous. These vasomotor disturbances may 
also occur in the mucous membranes of the nose and 
throat, causing them to appear pale. 

The fever usually lasts only a few days, but it may 
persist for even as much as two weeks. There seems 
to be no characteristic range of temperature in this 
disease. The intensity of the beginning symptoms 
seems to be no indication of future severity or of 
future paralysis. On the other hand, an attack with 
mild early symptoms may be followed by serious 
paralysis and a dangerous condition. 

Not only is flexion of the head sometimes combated 
by the patient on account of the pain, but also flexion 
of the spine often causes pain, a symptom of diagnostic 
importance. 

DIAGNOSIS 

The most frequent early symptoms above described, 
especially if an epidemic is in progress, should suggest 
the possibility of poliomyelitis. If there is stiffening 
of the back of the neck and pain on bending the spine, 
the presumptive diagnosis is poliomyelitis, and should 
lead to immediate lumbar puncture for a positive diag- 
nosis. Careful examination of the extremities may 
show, even in a young child, a slight difference in 
the movement of the arms or legs, and such begin- 
ning paralysis may occur early in the disease. A 
diagnosis should, of course, be immediately clinched 
by lumbar puncture. However, it should be noted 
that many patients with this infection do not show 
paralysis, and may not show muscular weakness, and 
may not show stiffening of the muscles, early in the 
disease. Also, the temperature may drop in a day 
or two, to rise again later. Consequently it should 



122 POLIOMYELITIS 

be urged that a patient with the symptoms described, 
during an epidemic of poliomyelitis, even without 
positive diagnostic symptoms, should either have lum- 
bar puncture made to clear up the diagnosis or should 
be under suspicion for a week or ten days. If polio- 
myelitis is suspected, though the symptoms are indefi- 
nite and lumbar puncture is not allowed, the patient 
should be isolated for two weeks. 

It may be briefly noted that cerebrospinal fever is 
similar in the beginning to poliomyelitis, with per- 
haps more tendency to vomiting, and with generally 
an eruption. There is more stiffening of the neck 
and less pain, early, in the lower back and legs. 
Tuberculosis meningitis is never as rapid in its onset 
as either of the above infections. 

LUMBAR PUNCTURE 

When lumbar puncture is made for diagnostic 
purposes it should be remembered that normal spinal 
fluid contains not more than 10 cells per cubic milli- 
meter, and in poliomeylitis the number is increased 
to 20, and at times to even more than 100. 

Ruhrah (Amer. Jour. Med. Sci., Feb., 1917, p. 178) 
states that in the early stage of the disease the poly- 
morphnuclear cells are found increased, while after 
paralysis has occurred the chief increase is in the 
lymphocytes. He states that this increase in the 
number of cells in the spinal fluid disappears in about 
two weeks. 

If the fluid withdrawn is clear, the mononuclear 
cells will predominate; if it is opalescent, as it occa- 
sionally is, the polymorphnuclear cells are increased. 

Of course if there is an increase of fluid in the 
cerebrospinal canal there is increased pressure, and 
the amount of pressure is indicated by the speed with 
which the fluid is discharged at the time of puncture. 
The quantity of fluid obtained varies from 10 to 
50 c.c. 

Pain in the majority of cases is relieved by lumbar 
puncture. Also many head symptoms are relieved by 
the evacuation of the fluid which is under pressure. 
Consequently, lumbar puncture is a therapeutic meas- 
ure of distinct value. 



PARALYSIS IN POLIOMYELITIS 123 

Charles Dana (Jour. A. M. A., April 7, 1917, p. 
1017) describes a condition that not infrequently 
occurs, namely, what may be termed "puncture head- 
ache." This rarely begins until the day after the 
fluid has been removed from the spinal canal. It is 
not serious, and does not last long, but may be quite 
severe. The pain is diffused over the head and even 
over the eyebrows, or it may be mostly occipital. Dana 
finds this pain, with various remissions, may last five 
to ten days, or even longer. He also finds it is more 
likely to occur when there is a small amount of fluid 
in the spinal canal, and hence low pressure, than when 
there is high pressure, with extra fluid in the canal. 
This, of course, is logical, especially as he interprets 
the condition to be due to the fluid removed from 
the spinal canal, allowing the water pad of the brain 
to be diminished so that the brain temporarily rests 
on the cranial bones and thus causes this headache. 
Therefore to prevent this "puncture headache" he 
would withdraw the fluid very slowly, and keep the 
patient horizontal for three or more days. 

Zingher (Jour. A. M. A., Mar. 17, 1917, p. 817) 
states that "the injection of immune or normal human 
serum into the spinal canal during the acute febrile 
stage of poliomyelitis causes a distinct cellular reac- 
tion which is mostly polynuclear in type." He 
believes these polynuclear cells have a phagocytic 
action. 

PARALYSIS 

As previously stated, when flexing the head and 
bending the body — in other words, when movements 
of the spine and consequent irritation of the spinal 
cord — cause pain, poliomyelitis is frequently the 
cause. However, without these symptoms paralysis 
may develop at any time, from even twelve hours 
to many days, and Ruhrah states that paralysis may 
occur as late as twelve days after the beginning of the 
disease. 

It should again be emphasized that the severity of 
the beginning symptoms seems to bear no relation to 
the amount of paralysis that may follow ; severe onsets 
may not be followed by paralysis ; mild onsets may 
be followed by multiple paralysis and death. Severe 



124 POLIOMYELITIS 

abdominal pain may occur, even simulating condi- 
tions that call for operation. There may be trem- 
blings or tremors of one or more extremities, espe- 
cially on the attempt to move these parts. 

The most frequent parts paralyzed are the legs, 
either one or both. LeBoutillier (Amer. Jour. Med. 
Sci., Feb., 1917, p. 188) states that in 25 per cent, of 
all cases one or both legs are involved, in 12 per cent, 
one or both arms. In the severest cases the muscles 
of the trunk are involved, even those of the neck, and 
death occurs from failure of respiration. The most 
frequent muscles paralyzed, in the order of their fre- 
quency, according to Ebright {Jour. A. M. A., Sept. 
1, 1917, p. 694), are the "anterior foot muscles, quad- 
riceps, glutei, hamstrings, deltoids, hip flexors, inter- 
nal rotators of the thigh, and external rotators of the 
shoulder." He also declares that "a stretched muscle 
will not regain its tone." 

It has even been suggested that most cases of 
scoliosis are due to frank or undiagnosed polio- 
myelitis. 

Some statistics from the New York epidemic 
showed that two-thirds of the cases had paralysis that 
lasted longer than the quarantine, while about 15 per 
cent, never had paralysis, and about 15 per cent, more 
had short-lived paralysis. 

EARLY TREATMENT 

The early treatment should take into consideration 
the prevention of the infection of others, even on a 
doubtful diagnosis, i. e., before the diagnosis has been 
positively made. In other words, a suspected patient 
should be isolated, the room screened, all discharges 
disinfected, and all clothing sterilized. Of course as 
soon as the diagnosis is made the case should be 
reported, and all children who have been in contact 
with the patient should be isolated for two weeks. 

It should be recognized that the nurse or other 
attendants may carry the infection in their nostrils 
or throats and yet not suffer from the disease. They 
may have become immune from previous attacks, or 
they may have a natural immunity, and still harbor 
the infection. The dust of a room in which a patient 



EARLY TREATMENT OF POLIOMYELITIS 125 

with the disease has been may carry the infection, 
and it is even stated that the streets and sidewalks 
may harbor it ; hence the spread of epidemics. Bath- 
ing in pools of water, or in tanks where the water is 
not frequently changed should be prohibited during 
an epidemic. While domestic animals have not been 
shown to harbor the infection, pet animals, as cats 
and dogs, might carry the infection in their fur. 

As peroxid of hydrogen, even in weak solutions, 
kills this virus, it should be used in 5 per cent, solution 
in warm water as a spray (two or three times a day) 
into the nostrils of all children who may have been 
exposed to the disease. Also the nostrils of the attend- 
ants of the patients should be so treated. The throats 
of young children should be sprayed, while older chil- 
dren should gargle, a little stronger solution of per- 
oxid of hydrogen, as 10 or 15 per cent. In three or 
four minutes after the peroxid of hydrogen solution 
has been used the parts should be sprayed or washed 
with a weak (not more than 1 per cent.) solution of 
sodium chlorid and sodium bicarbonate in warm water. 

The treatment of the preparalytic stage is the same 
as that of any other infection. The bowels should be 
thoroughly cleaned out with the purgative which 
seems most advisable. Food should be entirely 
stopped for twenty- four hours, and only water given, 
or at least only some simple cereal gruel, or milk. The 
patient should be absolutely at rest, with no mental 
or physical disturbance. The body should be gently 
cleansed with hot or warm water sponging, the tem- 
perature depending on the amount of the fever. Cold 
water sponging is inadvisable. If there is much pain 
the patient should be very gently handled, to cause 
the child the least possible muscle movement, and it 
may even be necessary, temporarily, to abandon 
sponging. 

Acute pain must be stopped with small doses of 
codein or of the deodorated tincture of ppium. The 
beginning dose may be small ; the frequency should be 
sufficient to render the child nearly free from pain 
and to cause some sleep. The lumbar puncture that 
should be done for diagnostic purposes often becomes 
a therapeutic measure of value, relieving the symp- 
toms of pressure and relieving pain. Puncture for 



126 POLIOMYELITIS 

therapeutic purposes may be done every day for sev- 
eral days, and may even be done more frequently, if 
symptoms of pressure are present. 

By the second or third day the nutrition of the 
patient should be carefully watched; the character 
and the amount of the food depend upon the height 
of the temperature and upon the ability of the stomach 
to digest. Some nutrition every three hours in the day- 
time and once or twice in the night is the best method. 
If it is not advisable to give meat broths or meat 
extracts, the child should receive small doses of iron 
almost from the beginning of the illness. One of 
the best methods of administering iron is a powdered 
tablet of the saccharated oxid of iron (Eisenzucker) , 
and a 3-grain tablet once a day is sufficient. 

If there is much restlessness and sleeplessness with- 
out acute pain, small doses of bromid may quiet the 
child, stop the pain and cause sleep. Coal-tar 
products and synthetic drugs, although they are more 
or less analgesic, should not be given these young 
children. Their depressant action is uncertain. Even 
salol is probably inadvisable. Although iodid of 
potassium has been recommended, there seems to be 
no excuse for it, except possibly in very small doses. 
Iodid of potassium has never been shown to cause 
absorption of exudate in acute conditions. A very 
small dose of iodid, whether as iodin, or as iodid of 
potassium or sodium, as a stimulant to the thyroid 
will be no more necessary in this infection than in 
any other infection. On the other hand, it may be 
advisable in all infections, as it is now known that 
the thyroid gland is always disturbed by every infec- 
tion and its detoxicant action in disturbed nitrogen 
metabolism is increased by a sufficiency of iodin. 

Acute pain and active symptoms may disappear in 
from a few days to two weeks after the paralysis. 
Until pain has ceased, all active measures aimed at 
the paralysis are contraindicated. The treatment of 
the paralyzed parts should be to put them in the most 
comfortable position possible by cushions, sandbags 
or branbags, so that stretching of paralyzed muscles 
and ligaments may, if possible, not occur, and that 
overaction of nonparalyzed muscles may be limited. 






SERUM TREATMENT IN POLIOMYELITIS 127 

Sometimes muscle spasm with pain is relieved by a 
warm water bag. Very hot water bags should not 
be used on the child's skin unless they are so covered 
that the heat is modified. Painful joints may be 
wrapped in cotton. 

Hexamethylenamin has been suggested ; but it has 
not been shown that this drug has any germicidal or 
antiseptic activity unless it meets acid media, as 
typically in kidney and bladder conditions. 

As soon as convalescence is established, the nutri- 
tion should be of the best. Fresh air is important, 
but rest and quiet for the patient should be continued. 
Small doses of iron should be given, and some little 
bitter tonic may be administered, if the appetite is 
poor. Small doses of sodium iodid may be advis- 
able, not more than 0.10 gram (1% grains) twice 
a day. Calcium in some form may be advisable, 
unless considerable milk is given the patient. 

SERUM TREATMENT 

As it was found laboratorily and clinically by Flex- 
ner and others that the injection of a serum from 
a person who had had poliomyelitis was more or 
less inhibitive to the advance of this disease and 
seemed to stimulate the production of antibodies in 
the individual to fight the disease, it seems advisable 
to obtain such blood serum, if possible, and to inject 
it, best intraspinally, and possibly later intravenously, 
into the afflicted patient. It is found to be more valu- 
able when given in the early stages, as is true in the 
antitoxic treatment of all diseases. The serum should 
generally be given intraspinally, and perhaps only 
intravaneously when there are signs of a general 
infection or complications have occurred. It may be 
given daily, or every two or three days for several 
doses, and the amount suggested has been from 5 
to 30 c.c. 

The pressure under which the fluid is given should 
be very carefully watched, and if pressure symptoms 
occur, the injection should immediately cease, and if 
necessary some of the fluid must be allowed to flow 



128 POLIOMYELITIS 

out of the canal. It may be administered at the time 
that for therapeutic or diagnostic reasons the fluid of 
the spinal canal has been withdrawn. 

On account of disturbing symptoms and the danger 
of increased pressure, Draper (Jour. A. M. A., April 
21, 1917, p. 1153) cautions that not more than 10 c.c. 
should be injected into the spinal canal, and then only 
when a larger amount of spinal fluid has been removed. 
In other words, increased pressure in the spinal canal 
must be avoided. He, however, believes that immune 
serum, when it can be obtained, should be given every 
child, and the earlier the better, as it seems to have 
been shown to be of the greatest value before paralysis 
has occurred. Still, until we have more positive data, 
during the progress of the disease, even if paralysis 
has occurred, the serum should be given, as it may 
cause improvement. 

It is hardly necessary to urge the necessity of a 
careful selection of the donor for this serum. The 
more recently he has recovered from poliomyelitis, the 
more active in antibodies must his serum be. How- 
ever, he may have had the disease many years before 
and the serum still, be of value as a therapeutic agent. 
Of course he should have no chronic disease. Syphilis 
must be excluded by a Wassermann or Noguchi test, 
unless the history of the patient and his family is abso- 
lutely known. The laboratory care and preparation 
of the serum for use is beyond the province of this 
review. Also the value or necessity of preservatives 
need not be discussed. 

SPECIFIC HORSE SERUMS 

Recent reports by Rosenow and by Nuzum and 
Willy on the treatment of epidemic poliomyelitis 
describe the preparation of a serum of immunized 
horses, for which excellent results are claimed. The 
horses were immunized with the coccus found in the 
central nervous system in epidemic poliomyelitis, and 
consequently the question of the exact relation of- this 
coccus to poliomyelitis is again raised. ' In both reports 
it is asserted that the serum used has protective and 
curative powers with respect to the experimental 
poliomyelitis of the monkey produced by means of 



SPECIFIC SERUMS IN POLIOMYELITIS 129 

poliomyelitis virus, that is, suspensions in physiologic 
sodium chlorid solution of fresh or glycerinated ner- 
vous tissue from human beings that have died with 
this disease, or from monkeys experimentally infected. 
While the coccus with which the horses were injected 
unquestionably occurs in poliomyelitis, and frequently 
may be present in the so-called virus, its exact rela- 
tions to the disease have not been made fully clear 
because thus far it has not been possible to produce 
poliomyelitis in the monkey by injections of this coccus 
in undoubted pure culture. But in spite of the lack 
of this essential link in the chain of evidence necessary 
to establish that the coccus is the cause of the disease, 
it must be acknowledged that if the serum of horses 
immunized with the coccus protects against and even 
cures poliomyelitis in the monkey, an adequate experi- 
mental basis for a thorough trial of such serum in the 
treatment of the human disease certainly has been 
provided. It is clear, however, that the results of 
further experiments on the action of the serum in 
monkey poliomyelitis are required before the claims 
in favor of its protective and curative powers may 
be regarded as fully established. 

In conclusion, it may be said that the injection of 
horse serum appears to be quite harmless in polio- 
myelitis; that the authors of the reports are deeply 
impressed with the apparent good effects of the 
serum; that their figures appear to show a great 
reduction in the death rate, but that the figures are 
probably not to be accepted without the reservation 
that they may seem more favorable than is actually 
warranted. The suggestion may be ventured that even 
if* it eventually should be found that serum produced 
as described in these reports has little or no specific 
effect on the essential cause of poliomyelitis, its use 
may be followed by favorable results due on the one 
hand to general nonspecific effects such as follow 
the intravenous injections of foreign proteins, and 
on the other hand to its action, specific in nature, on 
the coccus used in the immunization, which may be a 
secondary invader of no little importance in polio- 
myelitis. 



130 POLIOMYELITIS 



COMPLICATIONS 



These hardly need discussion, as each part affected 
must be treated in the best way possible, as it would 
be treated were this disease not its cause. A lung 
complication is very serious, as the danger is very 
great from anything that interferes with the respira- 
tion. If the muscles of respiration are more or less 
paralyzed, inhalations of oxygen, or artificial respira- 
tion, may be tried, but they are probably not often, if 
ever, life-saving. 

Secretions and exudates from any complicating 
inflammation should be thoroughly sterilized,, as they 
may carry the germ or virus of infection. 

CONVALESCENCE 

There is a difference of opinion as to whether a 
paralyzed patient should be long kept at rest in bed 
or should be allowed soon to begin to walk. There 
can be no doubt that anything that tends to fatigue 
is seriously injurious to the paralyzed muscles, and, 
also, anything that causes overactivity of the non- 
paralyzed muscles is not desired. 

It would seem, therefore, that each patient should 
be individualized as to the length of time he should 
remain flat in bed, with such passive movements and 
such gentle massage as seems advisable. As soon as 
improvement occurs the patient should probably begin 
to be about, with such protective apparatus as will 
prevent deformities and still allow locomotion, and at 
the same time be not so massive and weighty as to 
cause much fatigue. 

From the start, voluntary movements of paralyzed 
limbs and groups of muscles should be urged, and even 
after long months, and even years, of paralysis such 
voluntary attempts should be made, sometimes result- 
ing in wonderful improvement. Resistant massage, if 
the child is old enough to cooperate, is advisable, but 
the results must be carefully watched and tire pre- 
vented. 

Gentle faradism and gentle galvanism, of just suffi- 
cient strength to cause contraction of the muscles, is 
probably soon advisable; but electricity should not be 
used more than from 5 to 10 minutes in any one day. 



CONVALESCENCE IN POLIOMYELITIS 131 

Some clinicians believe electricity is of no value (espe- 
cially Lovett, Jour. A. M. A., Aug. 5, 1916, p. 421), 
but the majority of opinion is that, when properly 
used, it is of value in awakening the activity of 
muscles and nerves. However, artificial contractions 
are never of as much value as are even slight volun- 
tary contractions. 

Before electricity is applied the part should be 
heated with warm applications and gentle massage, as 
the circulation is always sluggish in a paralyzed part 
and the part is always colder than normal parts of 
the body. This massage, by stimulating the circula- 
tion of both blood and lymphatics, allows the elec- 
trical reaction to occur with less strength of current. 
Electric light heat, as suggested by Lovett, is a valu- 
able method of heating a chilled, paralyzed limb. 

It has been suggested that strychnin be injected 
into a paralyzed muscle during the convalescent stage, 
and the dose given has been quite large for a child. 
This may be tried where a muscle or muscle group 
is not awakened by ordinary means. One-sixtieth of 
a grain may be given a child five or more years old, 
and even larger doses have been given. 

Lovett, who has studied this disease very thor- 
oughly and written many articles embodying his 
observations, states that it is not generally recognized 
that the muscles of the back and abdomen become 
weakened in this disease, causing many deformities, 
especially if the child too long sits. Deformities in 
these cases should be prevented by proper jackets or 
corsets. 

Skilled muscle training and the advice of an ortho- 
pedic surgeon is essential in the management of these 
paralyzed children, even in the convalescent stage. 
Drop foot, or eversion, or inversion must be, if pos- 
sible, prevented. Rotation or deformity of the knees 
must be noted and prevented, if possible. A group 
of muscles may not be actually paralyzed, but exer- 
cise with these muscles may show an *unusual tire of 
one leg as compared with the other, or one arm as 
compared with the other, and such an extremity needs 
watchful care and treatment. 

Finally, in this stage of convalescence it should be 
urged that all massage, applications of electricity, and 



132 POLIOMYELITIS 

exercise should be done by skilled hands and with 
skilled advice. Also, the paralyzed limbs, and per- 
haps the whole body, should be kept extra warm by 
proper clothing, depending upon the age of the patient, 
the season of the year, and the climate. Chilled limbs 
do not recover as do limbs that are kept thoroughly 
warmed. 

prognosis 

The early prognosis as to fatality should be very 
carefully made, even in mild cases, up to the latter 
part of the first week. The actual death rate varies 
greatly in different epidemics, perhaps roughly from 
10 to 20 per cent., or even higher. 

While a few patients have no paralysis, many of 
these will be found to have weakening of some 
muscles. Such weakening of muscles and actual 
paralysis may rapidly recover, even in a few days, but 
most paralyzed patients will not recover for several 
weeks or even months, while perhaps the majority 
of those who have suffered paralysis will never again 
have perfect muscle power. Some patients may 
recover without scientific orthopedic or other medical 
treatment, but the possibility of such recoveries with- 
out deformity should not be depended upon. There 
can be no question that scientific, careful manage- 
ment of the paralyzed patient and of each paralyzed 
limb may cause progressive and continued improve- 
ment for months and even years, while any misman- 
agement, as overexertion, fatigue, or misdirected and 
overused measures for improvement will certainly 
retard recovery or ev*en prevent it. 

As previously stated, respiratory paralysis is a most 
common cause of death, and oxygen inhalations, arti- 
ficial respiration and other artificial respiratory meth- 
ods may prolong and possibly save life. It has been 
suggested that turning the patient from side to side 
may prevent dangerous edema in the vital nervous 
tissues. 

It should be remembered that in apparent improve- 
ment in this disease serious relapses may occur. When 
the disease attacks an adult it seems to be more seri- 
ous, and the prognosis not so good. 



LATE TREATMENT IN POLIOMYELITIS 133 

LATE TREATMENT 

Orthopedic advice should be sought early in the 
disease, as soon as paralysis occurs, or at least the 
best orthopedic measures should be taken to prevent 
deformities. During the stage of convalescence is 
the period when the orthopedist should either take 
charge of the patient or should be frequently enough 
consulted to insure the best possible management of 
the paralyzed child. The great necessity for rest and 
yet graded stimulation of weakened muscles has 
already been emphasized. Proper care at this stage 
prevents deformities that must be corrected surgically 
later. It cannot be too often repeated that voluntary 
effort is of the greatest possible value in awakening 
paralyzed muscles and groups of muscles. 

It has been shown that a muscle that is too long 
over stretched by a malposition of a limb or part of 
a limb cannot recover its vitality and strength. Hence 
such stretched muscles must be relaxed by proper 
splints or appliances. Although, as previously stated, 
electrical stimulation is not considered of value by 
some clinicians, it is urged by others that if a muscle 
responds to gentle faradism, such gentle daily treat- 
ments continued but a few minutes at a time will 
hasten recovery of the muscle. 

Lovett (Jour. A. M. A., April 7, 1917, p. 1018) says 
that improvement may go on for two years, and even 
if a muscle shows but a slight trace of power there is 
still hope, even after several years of paralysis. He 
emphasizes the danger from unnecessary braces, and 
the danger from not properly supporting the para- 
lyzed muscles. He especially urges that support be 
given to weak abdominal and weak back muscles. In 
other words, it requires the best of judgment to decide 
just what sort of spinal, or other supports, should be 
used. 

If a deformity persists after two years or more, 
surgical orthopedic measures may be instituted, such 
as the cutting of tendons or fasciae, the stretching of 
muscles; or more radical measures may be instituted 
in the way of bone and nerve surgery. 

When a brace is placed on a child, the mother 
should thoroughly understand that this is only a pre- 



134 TYPHOID FEVER 

vention of deformity, it is not a cure for the paral- 
ysis, and the child should either be treated at home 
or taken to some institution for continued muscle 
treatment. Such treatment may be artificial heat, as 
by electric light; massage; electricity; voluntary or 
resistant exercise; and, later, graded exercises some- 
times termed educational exercises, to re-educate a 
muscle or group of muscles to do its or their proper 
work. Heat and warmth to a paralyzed limb are con- 
stantly essential, as the nutrition of the whole part, 
muscles and nerves, improves under normal tempera- 
ture, while, on the other hand, nutrition is at a mini- 
mum when the part remains far below normal in tem- 
perature as compared with other parts of the body. 

In a communication by Lovett (Jour. A. M. A., 
July 21, 1917, p. 168) he states that it is a serious mat- 
ter for a child to attempt to walk on a paralyzed leg 
before the end of, the first year. He finds when the 
child walks too soon that many times a change from a 
partial to a total paralysis in the foot muscles occurs. 
He also notes that a paralyzed right hand recovers 
sooner than a paralyzed left hand. 

TYPHOID FEVER 

GENERAL PROPHYLAXIS OF TYPHOID FEVER 

Typhoid fever is one of the most preventable of 
all infectious diseases. The essential agent in the 
causation of typhoid fever, Bacillus typhosus, has been 
found in the blood, in the feces, in the urine, and in 
the bile. It cannot always be discovered in the early 
days of the disease, but in the second or third week 
it can generally be detected. It may persist for years, 
even as many as twenty-five or fifty, after a patient 
has become convalescent, and also in the body, par- 
ticularly in the feces and urine of persons who have 
never themselves, so- far as can be determined, suffered 
from an attack of the disease. These persons are 
known as "typhoid carriers." 

After diagnosing the disease as typhoid, the physi- 
cian should at once report the case to the health office. 
Even should the case be suspicious only of typhoid, 
the following precautions may well be taken. The 
feces immediately on being passed should be covered 



PROPHYLAXIS OF TYPHOID 135 

with a 5 per cent, solution of phenol, and the hard 
masses should be broken up so that the disinfectant 
will thoroughly penetrate the fecal matter and come 
in contact with all microorganisms which may exist 
therein. Other disinfectants may be used, such as 
chlorinated lime, or liquor cresolis compound, 2 per 
cent. The utmost cleanliness should be used by the 
attendants in connection with the movements of the 
bowels. The skin surrounding the anus should be 
carefully washed with a disinfectant solution, and the 
cloths used for this purpose should be put in paper 
bags and subsequently burned. The attendant also 
should, after bathing the patient, always wash her 
hands in a disinfectant solution. In a similar manner 
the urine should be discharged into a vessel and mixed 
with a disinfectant solution. 

The bacilli can sometimes be found in the sputum, 
and if the patient has any cough, the sputum should be 
collected on cloths and burned. 

All bedding should be soaked in a disinfectant solu- 
tion and boiled before being washed. The cups, 
glasses, dishes, knives, forks, spoons, and napkins used 
by the patient should also be disinfected before being 
washed. 

During convalescence, the feces, and the urine 
should be subject at intervals to bacteriologic exam- 
ination, to determine whether the bacilli are still pres- 
ent. It has been found that they may be absent at 
one time, and may reappear later, so that repeated 
examinations are necessary. The patient should be 
carefully isolated until repeated examinations have 
shown entire absence of bacilli, both from the feces 
and the urine. When these rules have been observed 
in the care of any patient suffering from typhoid, he, 
his friends, and the physician, will rest assured that 
there will be very little likelihood of his communi- 
cating the disease to anyone else directly or indirectly. 

As has been stated, the disease may be carried 
directly from the patient suffering from the disease, 
or from a so-called bacillus-carrier. The bacilli may 
be received directly by a person who does not possess 
immunity to the disease by handling articles, such as 
clothing or utensils used in eating, which have been 



136 TYPHOID FEVER 

contaminated by fecal matter, urine, or sputum from 
a typhoid patient. A far more common mode of infec- 
tion is the indirect method, which embraces infection 
through water and through various food supplies, 
especially milk and oysters. Many epidemics have 
been due to the infection of a water-supply from 
patients suffering with typhoid. 

Jordan {Jour. A. M. A., June 6, 1914, p. 1772) 
states the following rules, for the individual and the 
community in preventing typhoid : 

RULES FOR PREVENTING TYPHOID FEVER 

For the Individual: 

1. Keep away from all known or suspected cases 
of typhoid. 

2. Wash hands thoroughly before meals. Do not 
use "roller towels." 

3. Use drinking-water only from sources known to 
be pure, or if this is not possible, use water that has 
been purified by municipal filtration or by hypochlorite 
treatment or by boiling in the household. 

4. Avoid bathing in polluted water. 

5. Use pasteurized or boiled, instead of raw, milk. 

6. Select and clean vegetables and berries, that are 
to be eaten raw, with the greatest care. 

7. Avoid eating "fat" raw oysters and, in general, 
oysters and other shell-fish whose origin is not known. 

8. Be vaccinated against typhoid in all cases in 
which any special exposure is known or feared. 

For the Community: 

1. Insist on the hearty cooperation of all persons 
with an efficient health officer. 

2. Require notification and a reasonable degree of 
isolation of every known or suspected typhoid case. 

3. Exercise strict control over the disinfection of 
known typhoid excreta. 

4. Insist on pure or purified water-supplies. 

5. Require pasteurization of milk-supplies. 

6. Regard all human excreta as possibly dangerous, 
and control their disposition in such a way as to pre- 
vent contamination of food or drink. 



VACCINE AGAINST TYPHOID 137 

VACCINATION AGAINST TYPHOID FEVER 

The well informed physician needs no arguments 
to convince him of the efficacy of antityphoid vaccina- 
tion or that it is a desirable procedure. The universal 
adoption of this method of protection by every one 
of the armies involved in the great war, the very low 
typhoid rates prevailing among the troops of the 
various countries, the mildness of the disease which 
attacked the soldiers when they succumbed to the 
overwhelming doses of typhoid bacilli prevalent under 
the filthy conditions in the trenches in which they per- 
force must live — all this is sufficient evidence to con- 
vince even the most sceptical that antityphoid vaccina- 
tion actually protects. 

Occasional cases of typhoid did occur among those 
vaccinated against the disease. These cases have been 
explained on the ground that the immunity created is 
not permanent and that it may be insufficient to combat 
tremendous doses of organisms taken directly into the 
body on the drinking of badly polluted water. The 
fact that a few cases did occur among immunized men 
should not deter the physician from the belief that the 
vaccine yields protection. 

The incubation period of typhoid fever is about two 
weeks. Its duration, when there are no relapses, is 
about two months. This means two weeks of incu- 
bation, four weeks of more or less serious illness, and 
two weeks before the real convalescence. Young 
adults and youth are most likely to contract this dis- 
ease, although it may occur at any age. This is the 
age, then, for the greatest effort to be made to give 
protective inoculations. All nurses and members of 
hospital staffs ; students of colleges and seminaries ; 
employees, and those who are interned in work houses, 
jails, prisons and asylums ; men in lumber camps ; and 
all those who travel and are therefore subjected to 
varying water, milk and food-supplies, such as "travel- 
ing" men, engineers, seamen, tourists, and vacationists, 
should receive typhoid preventive vaccination. 

With all the advantages to an individual and to a 
community conferred by protection against typhoid 
fever by vaccination, the physician must also carefully 



138 TYPHOID FEVER 

consider what constitute contra-indications. It seems 
to be wise carefully to examine every individual to 
ascertain his condition of health before vaccination is 
done. It should not be done if he is suffering from 
any acute infection however simple, namely, a coryza, 
a pharyngitis, a tonsillitis, or any acute gastrointes- 
tinal disturbance, gonorrhea, syphilis, albuminuria, 
glycosuria, or the more serious conditions of chronic 
nephritis or diabetes. The injections should be made 
in the afternoon, and the active symptoms will gen- 
erally be gone by noon of the next day. Three injec- 
tions should be given at weekly intervals. 

The method of injection is as follows: Paint with 
tincture of iodin an area about 15 mm. in diameter at 
the insertion of the deltoid muscle. Inject subcutane- 
ously with sterile needles and the best vaccine the dose 
of killed bacteria decided on. Then paint the region 
with collodion and allow it to dry. If proper care 
is taken, no infection will occur, and, as above stated, 
a temperature reaction is rarely above 100 F., and 
perhaps never reaches as much as 102 F., even in 
exceptional instances. A severe reaction could only 
occur when there is some serious complication in the 
individual, as perhaps tuberculosis. All slight reac- 
tions are generally over in twelve hours and even 
severe ones are generally over in twenty-four hours. 

The local reaction is greatest after the first dose, 
less after the second, and least after the third. 
Typically, there is an acutely inflamed area, varying 
in size, not hard and indurated like an incipient 
abscess. The arm may ache, and the axillary glands 
may become tender. The local reaction is generally 
at its height in about ten hours, and generally nearly 
gone in twenty-four hours. Any more severe reaction 
would be due to contamination. 

The dosage for children should be based on the 
child's weight and not on its age. The recommended 
adult dose is based on a weight of 150 pounds. It 
seems to be necessary for continued protection to 
revaccinate children more frequently than adults, 
namely, in about three years. 

Various preparations are now available. In the 
vaccination of our troops over one million men were 



VACCINES IN TYPHOID 139 

injected with a triple vaccine consisting of 1000 million 
' typhoid bacilli and 750 million each paratyphoid A and 
B bacilli per cubic centimeter. The first dose is 0.5 c.c. 
and the second and third doses each 1 c.c. Inocula- 
tions are made subcutaneously at intervals of seven 
days. 

LIPOVACCINES 

Many troops of the United States were vaccinated 
with a vaccine of typhoid and the two paratyphoid 
bacilli prepared in an oily medium — so-called lipo- 
vaccines. On the basis of experimental work, it was 
believed that vaccines so prepared would permit the 
giving of the vaccine dosage by a single injection, thus 
avoiding the delay incident to the giving of the three 
separate injections with the saline vaccine. It was also 
believed that a vaccine so prepared yielded an immunity 
of greater duration. Although final and exact figures 
are not available, it is understood that results with 
these vaccines were disappointing in that the protective 
value does not appear in actual practice to be as great 
as that yielded by the saline vaccines. The general 
subject will be discussed in the later article on vaccine 
therapy. 

TREATMENT OF TYPHOID FEVER 

A. General Measures. — Needless to state, the patient 
with typhoid fever should be put to bed and kept 
quiet. The usual measures, such as the use of "a 
cleansing cathartic, should be instituted and simple 
fluid mixtures such as lemonade or citrate solution 
may be given. Patients should be encouraged to change 
the position in bed sufficiently often to prevent the 
occurrence of congestion of any of the viscera and the 
development of bed-sores. The hygiene of the mouth 
should be watched, as mentioned for other diseases, 
with scrupulous care. 

B. Diet. — Whether we have underfed our typhoid 
patients or overfed them, it seems that the evidence 
is very strong that milk alone is not the proper food 
for these patients. In fact, when we consider the 
frequent difficulty in its digestion, the large amount of 
it that must be given to satisfy the system either in 
calories or in protein, it would seem that we should 
rule against it as a typhoid diet. These facts imme- 



140 TYPHOID FEVER 

diately cause the decision that our old feeding of 
typhoid fever was wrong, and that we must select a 
new or modified food in this disease. 

It can not be questioned that the high temperature, 
rapid pulse, delirium, and that association of nervous 
symptoms called typhoid are not caused by the typhoid 
germ alone, but by a double infection, and the double 
or secondary infection is due to toxins or the products 
of secondary germs absorbed from the intestines. 

Tympanites is an indication not of typhoid fever, but 
of intestinal putrefaction and fermentation, and a 
mistake in the management of the bowels and of the 
food administered. 

It stands to reason, then, that primarily such food 
and arrangement of the movements of the bowels as 
cause the least tympanites and the least indigestion 
are of first importance in the management of typhoid 
fever. Secondly, the fooo! which, so far as possible, 
satisfies the requirements of the body for nutrition 
and at the same time satisfies the above requirements 
of easy and thorough digestion, should be the food 
of choice. 

A liberal amount of fat in the diet will send the cal- 
ories up, but not all patients bear fat well, especially 
early in the disease. Fat may be tried in the form of 
cream, of butter and of yolk of egg. Coleman has 
been able to give as much as 200 or 250 gm. of fat 
per day without causing digestive disturbances. The 
fat content of ordinary milk is of course considerable, 
and milk in amounts of from 1.5 to 2 liters per day can 
be given to most patients without difficulty. 

Fruit juices, to which lactose has been added, may 
be given, as long as there is no diarrhea, but they 
should be discontinued should diarrhea develop. It 
must be remembered, however, that patients on a high- 
calory diet ordinarily have from two to four stools a 
day. 

It should be continually borne in mind that indi- 
vidual patients may not thrive under a high-calory 
diet. Should tympanites or other digestive distur- 
bances begin to appear, it is well to modify the diet 
at once and especially to restrict the intake of milk 
and of lactose. If, on the high-calory diet, examina- 



TREATMENT OF TYPHOID 141 

tion of the stools shows that undigested food is pass- 
ing through, the diet should be reduced. 

A good mixed diet for twenty-four hours, suitable 
for an ordinary adult ill with typhoid fever, is repre- 
sented by one pint of milk; two eggs, or the whites of 
three eggs; one cup of thoroughly cooked, thin oat- 
meal gruel; the juice expressed from a pound of 
chopped round steak; a small cup of coffee, in the 
morning; a small portion of orange or lemon jelly made 
from gelatin; and enough salt and sugar in the above 
to make them palatable. 

The milk may be administered, hot or cold, with or 
without salt, with or without Vichy, with or without 
lime water, in two or three doses, as deemed best in 
the individual instance. Sometimes koumys makes a 
valuable substitute for ordinary milk. Sometimes but- 
termilk may be used, and this in large quantities. 

The eggs may be given raw, beat up with a little 
milk, or given with lemon juice on cracked ice, may be 
poached, or,. if the temperature is not high, soft boiled 
or in the form of boiled custard. 

The oatmeal gruel should generally be made with 
milk, and thoroughly cooked, strained, and salted to 
suit the taste. 

Meat juice is best prepared by just covering the 
chopped steak with water, and allowing it to stand for 
an hour and a half. The water and juices are then 
expressed out of the meat. This watery extract will 
then contain, besides the blood of the meat, actual 
muscle serum, which is a decided tonic, especially to 
the heart. This expressed fluid is then kept on the ice 
and administered, properly salted, in two or three 
doses. If the patient is not too ill, the food may be 
made more agreeable by allowing the patient to chew 
broiled steak, but not to swallow the fibrous portion. 

While gelatin is generally pleasant to most patients, 
it also has some nutritive value, and possibly tends to 
aid normal coagulation of. the blood, and perhaps pre- 
vents capillary bleedings from the inflamed intestines. 

A patient who is accustomed to his morning coffee 
need not be deprived of that pleasure because he has 
typhoid fever, unless there are meningeal symptoms, 
or meningitis is actually present. 



142 TYPHOID FEVER 

Experience seems to teach that it is best to adminis- 
ter nutriment to the typhoid patient in small amounts 
at three-hour intervals. It should, however, be 
arranged that the patient has normal rest. In other 
words, he should not be awakened from a comforta- 
ble sleep because it is time to do something to him or 
for him, and at regular three-hour feeding intervals 
should be the periods at which he is to be disturbed for 
other treatments. During the night, if he is not seri- 
ously ill, he should not be disturbed as often as every 
three hours. 

With the treatment outlined and, with proper care 
of the mouth, the patient's tongue is rarely badly 
coated and generally moist, and there should be no 
nausea or tympanites. 

C. Colon Enemas. — It has been lately shown that 
fecal deposits, seeds or other food debris may become 
lodged in the lower corner of the ascending colon, the 
cecum, and may cause inflammation or symptoms of 
appendicitis, and may even be a subsequent cause of 
appendicitis. Hence it may be found to be good treat- 
ment, in the first few days of typhoid fever, to give 
colon enemas of from one to two quarts of warm 
water, the patient lying on his right side, to aid in 
washing away the possible accumulations in the cecal 
region. Such colon washings can certainly do no harm 
in the first days of typhoid, and may be of marked 
benefit in the future course of the disease. In other 
words, the more thoroughly the pathologic process in 
the intestines, in typhoid fever, is considered from a 
surgical standpoint, with the aim to keep these ulcers 
and the inflamed intestinal mucosa as clean as possible, 
the less will there be secondary infection, the less will 
there be tympanites, the less will there be deep ulcera- 
tions, hemorrhages and perforations, the less high 
the fever, and the better the whole prognosis. 

D. The Fever. — Hydrotherapeutic measures have 
become so universal in the treatment of the fever in 
typhoid patients that it is unnecessary to describe these 
measures in detail. 

E. Medical Treatment. — Not only should the bowels 
be cleared at first, but subsequently the bowels should 
be moved daily. This is best done by administering 



MEDICAL TREATMENT OF TYPHOID 143 

every other day some . gently acting saline laxative, 
which cleans the upper part of the intestines, tends to 
drain the portal circulation, to keep the liver, our 
Pasteur filter, in a healthy condition, and to cause an 
easy watery movement. Any tendency to a diarrheal 
condition or to too many movements from such a 
laxative may be stopped by the administration of 1/10 
grain of morphin. The bowels are thus cleaned and 
subsequent excessive peristalsis inhibited, and the 
patient is generally at rest for the remainder of the 
day. On the alternate day a small glycerin enema, 
administered with a glass syringe, consisting of a 
tablespoonful of glycerin and a tablespoonful of 
water, will cause within ten minutes a movement 
of the bowels that will at least empty the descend- 
ing colon and cause the expulsion of gas. Such 
management of the bowels seems contra-indicated 
only by intestinal hemorrhage, signs of perfora- 
tion and great prostration. Such treatment also 
prevents secondary infections that keep the tempera- 
ture high. In other words, if the patient's bowels 
have moved daily artificially, and the movements are 
not caused by diarrhea due to irritation from the dis- 
ease, tympanites is not present and less antipyretic 
measures are needed. 

The best antiseptic to the upper part of the intestines 
seems to be salicylic acid in some form, and one of the 
best forms is the combination with phenol, viz., phenyl 
salicylate (salol), which may be given in capsules with- 
out any disturbance of the stomach, as it is there 
undissolved and breaks up in the duodenum. A small 
dose of this drug (0.25 gram or 4 grains) every six 
hours may be given continuously through the disease, 
unless there is a diminished execretion of urine, or 
albuminuria develops, or the urine shows darkening 
from the phenol, which would be very rare from this 
sized dose. Even the non-believers in bowel antisep- 
tics must admit that whether the colon bacilli or 
typhoid bacilli come to the upper part of the intestine 
by migration, or reach these regions through the blood 
stream, it would not be so healthy for them provided 
salicylic acid was present in the upper intestine as 
though it were not present. 



144 TYPHOID FEVER 

Thus far sour milk treatments, lactic acid germs and 
the administration of yeast have not been mentioned. 
Certainly bowel infections of most kinds are made bet- 
ter by the administration of yeast. The value of sour 
milk treatments in typhoid fever must be determined 
by experience. A patient, however, who is not doing 
well on the diet above suggested should be put on the 
sour milk treatment. One of the principle objections 
to such treatment is that the patient's stomach soon 
objects to any one diet that is to be long continued, 
although for a few days he might accept the soured 
milk. On the other hand, most patients do not object 
to the sour drink produced by the solution of a five- 
eights inch cube of a compressed yeast cake in a glass 
of water, given two or three times a day. 

F. Vaccine Therapy. — It is difficult to arrive at a 
just estimate of the value of vaccines in the treatment 
of typhoid fever, because the evidence for and against 
their use is derived from two widely different sources. 
From a theoretical standpoint, such a procedure has 
little justification. It is well known that there is an 
extensive invasion of the blood by the infecting organ- 
ism early in the course of the disease, and it seems 
reasonable to assume that these invading organisms 
furnish sufficient antigen stimulus to cause the maxi- 
mum antibody formation. On the other hand, if this 
antibody formation is delayed early in the course of 
the infection, vaccines may be of value in stimu- 
lating such a response. In the field of clinical medi- 
cine, many observers have reported striking results 
from the use of vaccines, and it is the common opinion 
of these clinicians that they are efficacious in the treat- 
ment of typhoid fever. 

The type and dosage of the vaccine have had no 
apparent influence on the results obtained. Sensitized 
vaccines have been strongly advocated by Besredka, 
Metchnikoff, Garbat and others, and on theoretical 
grounds such vaccines would be favored; but the 
majority of investigators have had good results with 
suspensions of dead bacteria prepared according to 
Wright's method. 

Although autogenous vaccines generally have been 
preferred, stock vaccines prepared from organisms 



TYPHUS FEVER 145 

selected for their high agglutinogen^ power have been 
efficacious in the hands of many. Reports have been 
so uniformly favorable with all preparations, that it 
seems as if the type used is of secondary importance. 

G. Convalescence. — The patient should be kept in 
bed until the pulse regains its normal rapidity, the 
blood pressure is not too low, and the amount of 
exercise that he is allowed to take should not be such 
as will much increase the action of the heart beyond 
the normal rate. The patient should first be allowed 
to sit up in bed. If this results in a marked increase 
in the heart rate, he should not be allowed to get up. 
It is also important that the nervous system should 
not be subjected to unusual irritation, and he should 
avoid cares and worries as far as possible. Any anemia 
should be treated as mentioned in connection with other 
infectious diseases. Protracted rest and a simple diet 
are essential features of this protective treatment. 

Before releasing the patient from observation the 
stools and urine should be examined repeatedly for 
the presence of typhoid bacilli. 

TYPHUS FEVER 

The recent developments in our knowledge of the 
etiology and transmission of this disease have been 
largely due to American investigations. These ad- 
vances have resulted from the clinical observations of 
Brill and the experimental work of several scientists, 
notably Ricketts, Anderson and Goldberger. 

Typhus fever is of microbic origin, but the infec- 
tive agent has not yet been determined with cer- 
tainty. Studies by Plotz indicate that it is a minute 
bacillus, and while these studies have been generally 
accepted some European observers (Nicolle) are still 
inclined to doubt that the organism he describes is 
the one which causes the typhus which they have 
observed. While the etiology of the disease has just 
been determined, its mode of transmission has been 
worked out so that we are able to take reasonably 
efficient means for its prevention. It has been well 
demonstrated that the disease is communicated by the 
body louse and probably also by the head louse. This 
observation explains many puzzling features, for 



146- TYPHUS FEVER 

example, as McCrae remarks, the decrease of the 
danger of infection when the patient was removed 
to a hospital and the great danger to attendants in 
epidemics, to which Murchison drew attention. 

The transmission of the disease to monkeys has 
enabled it to be made the subject of exact experi- 
mental work. Typhus fever formerly was very preva- 
lent in epidemics, and also as sporadic cases, being 
known under the names of jail fever, camp fever, 
ship fever, etc., terms which indicate its close associa- 
tion with overcrowding and filth. With the progress 
of sanitary science, the prevalence of the disease 
decreased until it appeared to have vanished with the 
march of civilization, especially in this country. 

In the United States the disease, in its typical form, 
has been found usually in ships coming into our sea- 
ports. A mild form of the disease has been discovered 
even in our farthest inland cities. It is important that 
the existence of this mild form should be borne in 
mind not only as explaining many puzzling cases but 
also as the possible source of epidemics when the 
organism may assume unusual virulence or the oppor- 
tunity for transmission be unusually great. 

The epidemic form, according to Brill, usually begins 
rather suddenly with a chill or chilly sensations, 
though it may occasionally be preceded by two or 
three days of malaise and general body pains, Head- 
ache rapidly supervenes and fever immediately 
appears. These symptoms are quickly augmented, so 
that by the second or third day the fever may have 
reached 104 or 105 F. As the disease progresses it is 
marked by profound toxemia, signs of intense blood 
infection, marked involvement of the nervous system 
manifested by delirium, excitement and tremor, and 
somnolence, stupor, coma vigil, and an unusually severe 
involvement of the muscular system as well, with the 
tremor and physical exhaustion which were so often 
manifested. 

Epidemic typhus fever is a disease of the winter 
months and is highly communicable. The endemic or 
mild form of typhus fever and the epidemic typhus 
fever are alike in their onset, in the first stage of the 



INFLUENZA 147 

eruption, in the critical decline and both are termi- 
nated, not followed, by relapses. In all other respects 
they differ. The eruption in the mild form (Brill's 
disease) rarely goes to the hemorrhagic stage; it is 
always an erythema. There is no profound involvement 
of the nervous system ; there may be a slight delirium, 
but it is mild in type, appearing only at night. The 
patient is never, or rarely, stuporous, never seized by 
maniacal excitement, never goes into coma vigil, and 
has no muscular tremors, subsultus, or carphology. 
Involuntary discharge of urine and feces are not seen 
in the mild form of typhus fever. In the mild form 
the headache, instead of diminishing about the eighth 
day as in the epidemic form of the disease, becomes 
progressively more intense even up to the end of the 
illness. The mortality of the mild form is less than 
0.25 per cent. 

The prevention of the spread of this disease is a 
comparatively simple problem, although, as experience 
in the present war shows, it may be very difficult of 
accomplishment. It consists essentially in the destruc- 
tion of vermin. This involves, of course, at the same 
time the removal of filth, the cleaning of the. inhabi- 
tants, and the prevention of accumulation of waste. 
The treatment should be symptomatic following the 
suggestions made for other infections. 

INFLUENZA: GRIP 

During the latter part of 1918, extending into 1919, 
and again in the early weeks of 1920, a pandemic of 
influenza and influenzal pneumonia appeared all over 
the world and caused as great a mortality as any other 
epidemic in the world's history. Probably more articles 
appeared in the literature on this subject than on any 
other subject which concerned the medical profession 
during that time. It would be impossible, and in fact, 
undesirable to review here all this literature or even 
to consider the articles dealing with treatment. Suffice 
to say that there is no good evidence that any treatment 
other than that purely symptomatic had any specific 
virtues in controlling the disease. 



148 INFLUENZA 



ETIOLOGY 



The organism described by Pfeiffer in 1891 has long 
been known as the influenza bacillus and good obser- 
vers have found it constantly present in cases of this 
disease. On the other hand, there has never been con- 
vincing evidence of its relation to influenza, for it is 
frequently found in many other diseases as well as in 
normal throats. It should also be borne in mind that 
there are a number of organisms varying greatly in 
pathogenicity, which are grouped under the name of 
Pfeiffer's bacillus. Many observers have claimed that 
the disease is due to a filterable virus and there is good 
evidence both for and against this claim. Mathers 
found a green producing streptococcus in many cases 
dying of this disease and other workers have been able 
to find it quite constantly present. In those cases with 
pneumonia — many observers have insisted that every 
case seen during the epidemic also showed pneumonia 
— all of the usual organisms invading the respiratory 
tract have been found including the various types of 
pneumococci, streptococci, Friedlander's pneumobacil- 
lus and even staphylococci. It is also pointed out that 
the pneumonia is not of the usual lobar type but a 
bronchopneumonia with no definite areas of consolida- 
tion, absence of the usual fibrinous pleural exudate, 
extreme wetness of the lung, and blood stained pleural 
fluid. 

PROPHYLACTIC VACCINATION 

In the face of the tragic attack of this disease 
numerous workers prepared vaccines which it was 
hoped would have definite virtue in preventing the 
disease. Vaccines were made of single strains of 
PfeifTer's bacillus, polyvalent vaccines of the same 
group, and all sorts .of mixtures were made, based on 
the bacteriological findings in various communities. It 
may be unnecessary to say that the bacterial flora dif- 
fered in various parts of the country and in different 
persons in various places. Most of the workers have 
been exceedingly optimistic concerning their results. 
On the whole, however, the concensus of the best 
opinion has been voiced by McCoy: "The general 
impression gained from uncontrolled use of vaccines 



PROPHYLAXIS OF INFLUENZA 149 

is that they are of value in the prevention of influenza ; 
but, in every case in which vaccines have been tried 
under perfectly controlled conditions, they have failed 
to influence in a definite manner either the morbidity 
or the mortality." 

GENERAL PROPHYLAXIS 

During the time of epidemic health officers every- 
where were alive to the condition and it is doubtful if 
any person in the United States was not to some extent 
reached by the literature and advice circulated. The 
measures in brief include : Staying away from crowds, 
isolation of the sick when feasible, avoidance of hand 
to mouth infection ; the wearing of a suitable face mask 
by those in immediate attendance on the sick; plenty 
of sunlight and fresh air; the avoidance of dampness 
and undue exposure to rain, snow and the elements ; 
early rest in bed in a warm room during the first signs 
of the disease. In addition^ the usual precautions 
attendant on acute infectious diseases should be 
employed. 

SYMPTOMATOLOGY 

It is doubtful whether any physician needs to have 
the symptoms described for him. The patient nowa- 
days can almost make a diagnosis. The small blood 
vessels all over the body seem to dilate and produce 
capillary congestion, especially of the mucous mem- 
branes, the' most frequent result being coryza, a 
pharyngitis, a laryngitis or a tracheitis. The conges- 
tion in the larynx causes the harsh, dry, metallic cough 
which is quite characteristic of this type of influenza. 
The congestion and swelling of the mucous membrane 
of the trachea causes a peculiar oppressed feeling with 
more or less pain, referred to the upper part of the 
sternum. The great amount of sneezing which occurs 
with a typical attack, almost similar to hay-fever, is 
due to congestion of the mucous membrane of the 
nostrils. The conjunctivae may also be injected, 
causing pain in the eyeballs and often a conjunc- 
tivitis, another typical symptom of influenza. In some 
seasons there seems to be a special tendency to middle- 
ear inflammations. At other times there frequently 



150 INFLUENZA 

occurs a congested drum, with sometimes a hemor- 
rhagic bleb or vesicle on the drum, a very painful 
though easily remedied condition. 

The almost constantly present lumbar backache at 
the onset of this disease is probably due to congestion 
of the kidneys, and albumin is frequently found in the 
urine of such patients, and occasionally blood cor- 
puscles. A menorrhagia or a metrorrhagia may occur 
from the same tendency to dilatation of the blood- 
vessels. There may even be nosebleed, and occasion- 
ally a slight hemoptysis without any other assignable 
cause and without any subsequent development. With 
this disease, although the fever may be high, the skin 
is likely to be moist, and there may be a profuse per- 
spiration. The pulse may be slower than we normally 
expect from the height of the fever, and the blood- 
pressure is generally lowered; all of these conditions 
are due to the tendency of the blood-vessels to dilate. 

The heart is generally weak from start to finish in 
this disease, and even collapse turns can occur. 

Rather an infrequent type of the disease is the 
bowel type; this can occur without respiratory catar- 
rhal symptoms. Patients so affected have diarrhea, 
with more or less intestinal irritation, apparently the 
greatest amount of dilatation of blood-vessels in these 
cases occurring in mucous membrane of the intestinal 
tract. These various types, the catarrhal, the nervous 
and the abdominal, may be interwoven, and a patient 
may show symptoms of all three. 

The future of every case of influenza is prostration, 
nervous and muscular debility, with more or less cir- 
culatory weakness ; in other words, there is exhaustion. 
The patient's resisting power is reduced, and any 
defect or diseased condition that he may have is aggra- 
vated by an intoxication with this germ. 

If no complications occur, the convalescent patient 
should rest as much as possible, should not be sub- 
jected to exposure and should be given tonics, and, if 
necessary to cause restful sleep, for a short period at 
least, some hypnotic or some physical method of caus- 
ing sleep. The most frequent complication is pneu- 
monia, and the type of pneumonia that the influenza 
germ seems to cause most frequently is the lobular or 



TREATMENT OF INFLUENZA 151 

bronchial pneumonic type; pneumonic congested areas 
may be found in different parts of one or both lungs. 
Not infrequently, however, true lobar pneumonia 
occurs. 

The next most frequent complication, as suggested 
above, is the middle-ear inflammation. The various 
sinuses in the region of the nostrils may become 
affected; all types of indigestion may occur, and not 
only sleeplessness and meningismus, but also a very 
serious meningitis, and even insanity can be caused by 
these germs and their toxins. Mental depression is 
a common occurrence, following severe attacks of 
grip. Pericarditis and endocarditis occur as complica- 
tions of influenza. 

It is thus seen that this disease should always be 
taken seriously, and every possible means used to pre- 
vent contagion, as it is one of the most highly con- 
tagious diseases. It spreads with great rapidity, but 
only by contact, although it may doubtless be trans- 
mitted by infected clothing, and perhaps even by let- 
ters. 

TREATMENT 

It would appear that almost every drug or prepara- 
tion in the Pharmacopeia has been recommended and 
tried in influenza and, indeed, a great many more that 
are not in any Pharmacopeia have also been strongly 
recommended and tried. Among those for which spe- 
cific virtues have been strongly claimed are : intra- 
venous injection of camphor oil, camphorated oil with 
guaiacol, intravenous use of mercuric chlorid, intra- 
venous injections of hexamethylenamin, quinin by 
every route in large doses, colloidal gold, calcium 
chlorid, diphtheria antitoxin, and tetanus antitoxin. 
As suggested by Herrick, "someone has blundered in 
reaching conclusions." 

It having been determined or suspected that a 
patient has influenza, it is much more important that 
he remain in bed, or at least in the house, than if he 
has an ordinary acute cold. Also, it is more essential 
that he be more or less isolated or that measures be 
taken that he does not spread the disease by spraying 
from coughing or sneezing, and that he does not use 
the same towels, napkins, drinking-cups and eating 



152 INFLUENZA 

utensils as other members of his family. The patient 
should be prohibited from fondling and kissing chil- 
dren. If the patient is a young child in close contact 
with the mother or nurse, all possible precautions to 
prevent contagion should be taken. 

In a word, each family should be taught that grip 
is an infection, that it is contagious, that it spreads 
rapidly, that it may have serious complications and 
that it frequently leads to pneumonia, which has 
become in many regions of this country the most fre- 
quent cause of death. As previously stated, whether 
a schoolchild begins with an acute cold or an influenza, 
he should be sent home and remain there until he is 
well. 

As a grip patient is liable to have a chill, or at least 
feel chilly or have cold sensations up and down the 
back, anything that makes him warm improves his 
condition. He may be given hot malted milk, hot tea 
or hot lemonade, at more or less frequent intervals, 
until his chilliness has ceased. The patient may be 
given a hot tub bath and then put into a warm bed in 
a warm room as an efficient means of making him 
comfortable and relieving his internal congestion*. 
Hot water bags at the feet and extra coverings to the 
bed are often needed. A quickly acting stimulant is 
camphor, given in tablespoonful doses of the official 
water (aqua camphorae), in lemonade, every two or 
three hours. The various methods suggested for 
aborting an acute cold may be used in this disease. 
Much greater care must be exercised, however, if the 
patient has the influenza infection than if he has a 
simple cold, as to when he can return to his work or 
occupation, or be subjected to exposure to cold or 
dust, either in a house, building or outdoors. 

Soon the temperature rises and often . quite high, 
associated with severe headache, backache and irregu- 
lar pains in other parts of the body. At this time a 
drug such as acetanilid, antipyrin, acetphenetidinum, 
or acetylsalicylic acid will be of benefit, provided that 
the patient is not ambulatory, and that he is not to be 
subjected to exposure. With this depressing infection 
such treatment is not wise unless a patient is in bed, or 
at least remains in the house. 



DRUGS IN INFLUENZA 153 

The proper dosage of these drugs has already been 
suggested, and no one of them should be long con- 
tinued. The most depressant is undoubtedly acet- 
anilid, and perhaps the least depressant is acetphen- 
etidinum. Should depression occur after one of these 
drugs has been administered or from the disease, cir- 
culatory stmulants such as camphor or caffein should 
be given and the patient surrounded with dry heat. A 
hypodermic injection of strychnin sulphate, 1/30 grain, 
may be given to stimulate the nerve centers. The 
following prescription is suggested : 

Gm. 

I£ Acetanilidi 0|25 gr. iv 

Sodii bicarbonatis 1 10 gr. xv 

M. et fac chartulas 10. 

Sig. : One powder, with water, every two hours. 

Gm. 

B Acetphenetidini 1 [ 50 

Phenylis salicylates 1 1 50 aa gr. xxv 

M. et fac chartulas 5. 

Sig.: One powder every three hours. 

A combination of aspirin, camphor and Dover's 
powder will sometimes be found of value: 

Gm. or C.c. 

Ifc Ac. acetyl, salicylic 61 3 ii 

Pulv. camphorae 1 gr. xv 

Pulv. ipecac et opii 4| 3 iss 

M. et fac chartulas 20. 

Sig. : One powder every three hours. 

Where there is much irritation of the throat, gargles 
of salt solution and mild alkaline solutions are advised. 

When there is pain or headache suggesting involve- 
ment of the nasal sinuses, sprays containing epinephrin 
1 : 10,000 will often give relief by allowing the escape 
of retained secretions. 

But little food is needed during the first twenty- 
four hours of grip, and it should not be pushed even 
on the second day, if food is repugnant to the patient. 
He should have plenty of water and such simple liquid 
nourishment as he desires. As soon as the appetite 
returns, food should be pushed. The various catarrhal 
conditions should be treated as suggested under coryza, 
pharyngitis and bronchitis. Also, while the patient is 



154 INFLUENZA 

kept warm, he should have good fresh air in his room. 
This is essential with all infections, and especially 
with infections of the nose, throat and lungs. The 
bowels should be treated as indications call for. 
Simple laxatives may be given, if needed, or the sooth- 
ing bismuth subcarbonate, if there is intestinal inflam- 
mation. Phenyl salicylate (salol) may be given, if 
there is much fermentation in the bowels, or the 
Bulgarian form of lactic acid bacilli may be given for 
a few days. 

SERUM TREATMENT 

In the midst of numerous deaths from this disease 
and the subsequent panic, physicians tried practically 
every from of biologic therapy thus far known. 
Among other things all of the various antipneumococ- 
cus serums, the antistreptococcus serums, the non- 
specific proteins, normal horse serum and convalescent 
serum were tried. The evidence thus far available is 
not convincing that any of these measures have pro- 
ceeded farther than the experimental stage. Most 
rational, perhaps, is the use of convalescent serum 
under properly controlled conditions. The work of 
Hartman, McGuire and Redden in the U. S. Navy and 
of Stoll in the U. S. Army tends to show that, prop- 
erly used, this treatment cannot do any great harm, 
and it was their belief that in a small percentage of 
cases at least it had beneficial effects. 

USE OF DIGITALIS 

Herrick has stated that in his experience the remedy 
of greatest value was digitalis. Without waiting for 
alarming indications of failing heart to develop in the 
way of feeble tones, rapid action, arrythmia or dilata- 
tion, digitalis was given by the mouth, hypodermically 
or intravenously in small or large doses as the need 
arose. It may be stated incidentally that a good prep- 
aration of digitalis given by mouth should give definite 
action within four to six hours, making its intravenous 
use unnecessary. 

CONVALESCENCE 

As soon as the patient begins to convalesce, he 
should be given tonics and if there is no inflammation 



PNEUMONIA 155 

in the ears, quinin is valuable. Some form of iron 
should generally be given, and possibly a bitter tonic 
before meals. If the patient is not nervous, a small 
dose of strychnin three times a day is good treatment. 
On the other hand, it should be urged that strychnin 
stimulation is overdone, and a patient who cannot sleep 
should not be given strychnin or quinin later than the 
noon meal. 

CONCLUSION 

The management of influenza should be as rational 
and simple as that of a case of typhoid fever. The use 
of drugs should be entirely symptomatic, and when 
they have served their purpose they should be dis- 
continued. In the article on pneumonia which follows 
will be found further information as to the treatment 
of the pneumonia frequently seen following influenza. 

PNEUMONIA 

Pneumonia is today the most serious acute infec- 
tious disease confronting the physician. Second only 
to tuberculosis among the acute infectious diseases as 
a cause of death, it attacks suddenly and kills quieklv 

Occurring usually in endemic form, it also appears 
frequently in epidemic form, and has become one of 
the most threatening of diseases. 

DEFINITION 

In outlining a plan of procedure to follow in the 
prophylaxis and treatment of pneumonia it is essential 
to have clearly in mind the causation and natural 
course of the disease. Pneumonia, or inflammation of 
the lungs, includes acute lobar pneumonia as well as 
various forms of atypical and bronchopneumonia. 

THE INFECTING ORGANISM 

Acute lobar pneumonia, due to infection by the 
pneumococcus, usually runs a rapid course, and is 
characterized by a diffuse exudative inflammation of 
large parts of one or more lobes of the lungs. Bron- 
chopneumonia, on the contrary, may be due to a 
variety of bacteria, but is usually associated with 



156 PNEUMONIA 

streptococci. Most cases of pneumonia which follow 
or complicate contagious diseases are due to strepto- 
cocci, i. e., are septic pneumonias. 

In pneumonia following influenza the clinical and 
pathologic picture is that of a streptococcus bacteremia 
with metastases in the lungs, joints, kidneys, serous 
surfaces, gallbladder and appendix. The prominent 
gross pathologic lesions are extensive hemopurulent 
pleuritis and pericarditis, marked hyperplasia of the 
lymph glands, parenchymatous degeneration of kid- 
neys, liver and myocardium. The lungs are usually 
only partially consolidated, very heavy and pliable. 
Often most of an entire lung may be involved. These 
cases correspond to those often observed in associa- 
tion with diphtheria, scarlet fever, measles, etc. The 
cases of pneumonia which occurred so extensively in 
connection with epidemics of measles in our training 
camps were in large part of this sort. 

While we have been in the habit of saying that lobar 
pneumonia is caused by the pneumococcus, recent 
studies have shown that strains of pneumococci which 
are alike so far as cultural properties are concerned 
are still widely separated in their biologic qualities. 

When the study of pneumonia at the Hospital of 
the Rockefeller Institute was undertaken, a large 
number of races of pneumococci were isolated and 
studied as to their immune reactions. Animals were 
immunized to each strain, and the blood serum of each 
immune animal was then tested as to its power to 
agglutinate each of the strains and also as to its power 
to protect mice from infection by each strain. As a 
result of these studies the strains of pneumococci 
grouped themselves into four classes or types. The 
serum produced by immunizing with each member of 
a group acted in a similar manner on all the strains 
of the group, agglutinating the bacteria and protecting 
mice against infection. On the contrary the serum 
produced by immunizing with a member of one group 
had no such power over the strains of the other 
groups. The four groups of pneumococci are spoken 
of as Types I, II, III and IV. Type I is foundln 
33 per cent, of cases of lobar pneumonia ; Type II in 



ETIOLOGY OF PNEUMONIA 157 

29 per cent. ;*Type III in 13 per cent., and Type IV in 
20 per cent. The pneumococci found in normal 
mouths belong to Type IV. 

These studies have a very important bearing on the 
prophylaxis and specific treatment of lobar pneumonia. 
Making use of the serum of animals which have been 
immunized against cultures of the four types of pneu- 
mococci, it is possible to test the strain from each case 
of pneumonia and to place it under the type whose 
corresponding serum causes it to be agglutinated. This 
is very important if immune serum is to be used, as 
the only cases of pneumonia which are benefited by 
serum are caused by organisms of Type I. 

In 448 cases studied in the Hospital of the Rocke- 
feller Institute. 145 were of Type I, 148 of Type II, 
55 of Type III and 100 of Type IV. Of these cases, 
pneumococci were found in the blood in 136 instances. 
The mortality when the organism was found in the 
blood was 55.8 per cent., whereas in the 312 cases 
with negative blood cultures, the mortality was only 
8.3 per cent. This shows that the presence of the 
pneumococcus in the blood during lobar pneumonia 
indicates a severe infection and n bad prognosis. 

In the pneumonias accompanying influenza in the 
great epidemics of 1918-1920 a varied bacteriology 
was found. Prominent organisms in addition to the 
various strains of pneumococci and streptococci were 
a green producing streptococcus isolated by Mathers 
whose finding was later confirmed by a number of 
other observers, the Pfeiffer bacillus and some of the 
ordinary cocci of the staphylococcus type. It seems 
doubtful that the exact etiology has been determined 
and "bacteriologists are inclined to the view that these 
cases are probably due to an infection with a minute 
filterable organism and that the bacteria which have 
been found are secondary invaders producing definite 
symptoms and complications. 

GENERAL CONSIDERATIONS 

Although pneumonia has been considered a self- 
limited disease tending to recovery, this can hardly 
be said to be generally true. The sthenic type of 
pneumonia which does tend to recovery, with one or 



158 PNEUMONIA 






more lobes distinctly involved, is now no't so frequent 
as a less circumscribed pneumonia, or an asthenic type 
with a low temperature and without much tendency to 
self-limitation and, as the statistics show, not a great 
tendency to recovery. The crisis which should intro- 
duce recovery means, according to Hektoen, the 
destruction of the pneumococci in the lungs and blood. 
This, he says, is accomplished by phagocytosis and by 
extracellular digestive processes. Therefore, the great- 
est defense against pneumonia is a production of leuko- 
cytosis and of antibodies in the blood. Such patients as 
rapidly die of a toxemia have this blood defense in 
insufficient amount. When this defensive process has 
been produced in sufficient amount rapidly to destroy 
the pneumococci, the recovery is by crisis; when it is 
in sufficient amount to destroy them only slowly, the 
recovery is by lysis. The latter form of recovery is 
the one that we now see most frequently. 

PREVENTION 

It has generally been considered that many persons 
harbor the pneumococcus in the mouth and throat, and 
that it is thus ever ready to attack the person who 
becomes debilitated, and especially to add its attack to 
that of the influenza bacillus or to follow a strepto- 
coccal infection of the throat or nose. There is no 
doubt that exposure and a weakening of individual 
resistance play a prominent part in the development 
of the disease. Recent studies of the incidence of 
the various types of pneumococci in the throats of 
normal persons, in the throats of those suffering with 
pneumonia, in healthy persons in contact with cases of 
pneumonia, as compared with those not in contact, and 
in the dust of rooms in which lobar pneumonia had not 
occurred, as compared with the dust of rooms in which 
cases of pneumonia had occurred, all show that pneu- 
monia, in a considerable proportion of cases at least, 
arises chiefly by infection from without. It was shown 
definitely that pneumococci of Types I and II are prac- 
tically never found except in the environment of per- 
sons ill of the disease or in the environment of carriers. 

It seems advisable, therefore, henceforth to regard 
every case of pneumonia as a focus for the spread of 



CARRIERS" OF PNEUMONIA 159 

the infection, and the same measures of prevention of 
infection of others should be instituted as have been 
found efficacious in other communicable diseases. 
These include primarily (a) isolation of the patient 
as far as possible, (b) collection of the sputum in spe- 
cial containers and its disinfection, and (c) sterilization 
and prevention of contamination from utensils, bed- 
clothing, personal clothing, handkerchiefs, and other 
material in close contact with the patient. 

The physicians, orderlies or nurses in attendance on 
patients with pneumonia should practice the greatest 
care in order to avoid transmitting the disease to 
others. This involves the wearing of a clean gown 
when attending patients, the thorough cleansing of 
the hands by soap and water before and after attend- 
ing each patient, and, as has been suggested by 
Weaver, the wearing of a simple protective face mask 
when in attendance on patients. This not only pre- 
vents the physician or other attendant from becoming 
infected, but also prevents the patients from becoming 
infected through their attendants with secondary infec- 
tions with organisms which they do not already have. 

The room in which the pneumonia patient lies 
should be kept as clean as possible, and after the 
patient's recovery it should be thoroughly aired, washed 
and sunned to dispose of any remaining organisms. 

Cases of the common contagious diseases, as measles 
and scarlet fever, in which secondary pneumonia 
occurs should be isolated and not allowed with uncom- 
plicated cases. 

CARRIERS 

Finally, a search should be made for pneumococcus 
carriers of the organisms of Types I and II especially, 
and these carriers should be instructed as to the pre- 
vention of the spread of the organisms. They may also 
be provided with a disinfecting mouth wash or gargle, 
and should use it persistently until the organisms have 
disappeared from the nose, throat and bronchial secre- 
tions. 

Kolmer and Steinfield refer to the studies of numer- 
ous observers who have shown the high pneumococ- 
cidal activity of ethylhydrocuprein hydrochlorid and 
of quinin preparations. They studied the possibility 



160 PNEUMONIA 

of disinfecting the sputum and the mouth with such 
preparations. The results indicated that 1 : 10,000 
dilutions of ethylhydrocuprein hydrochlorid or quinin 
bisulphate, in a 1 : 10 dilution of liquor thymolis con- 
stitute mixtures that may readily be used as mouth 
washes or gargles. Such a gargle may be used at least 
twice daily by those in contact with pneumonia cases, as 
well as by persons with pneumonia. Similar dilutions 
in Dobell's solution may be used for spraying the nose. 
For washing the mouth and gargling, a solution is 
conveniently prepared after the following formula: 

Gm. or C.c. 

B Ethylhydrocuprein hydrochlorid or quinin 

bissulphate ._ [02 

Liquor thymolis 20 j 

Distilled water to make 200| 

Liquor thymolis, which is used in the Philadelphia Polyclinic Hospital 
as a substitute for liquor antisepticus, is prepared after the following 
formula: benzoic acid, 64 grains; boric acid, 128 grains; thymol and 
menthol, each, 16 grains; oil of eucalyptus, oil of wintergreen and oil 
monarda, each, 4 drops; alcohol and glycerin, each, 4 ounces; water 
sufficient for 16 ounces. 

PROPHYLACTIC VACCINATION 

Vaccination against pneumonia with vaccines pre- 
pared from various organisms in saline suspensions as 
well as in oil — lipovaccines — has been given extensive 
and thorough trial. The evidence thus far available 
is quite conflicting and has been the cause of much 
acrimonious discussion. Early reports from military 
investigators were somewhat favorable, but these have 
been succeeded by denials of benefit. On the whole, it 
may be said that there is no evidence that prophylactic 
vaccinations against pneumonia even approximate in 
value the vaccinations against typhoid fever. The 
patient who is vaccinated should be informed that the 
protection is doubtful and that the vaccination is 
actually of the nature of an experiment. Polyvalent 
vaccines of pneumococci and all sorts of mixtures are 
available through commercial houses. The physician 
cannot protect against all the possible strains to which 
the patient may be exposed. It is doubtful whether 
protection is actually conferred against any. 






TREATMENT OF PNEUMONIA 161 

TREATMENT 

1. Rest. — The patient's rest should be as near per- 
fect as possible. Not only should the room be situated 
for the best possible fresh air, but it also should be as 
quiet as possible. It is often desirable that such 
patients receive hospital care and attention. If trans- 
fer to a hospital is to be made, the patient should not 
be allowed to stand, but should be moved with the 
least possible exertion to himself. Friends and rela- 
tives should not disturb the patient. Sleep and a quiet 
heart are more essential in pneumonia than in almost 
any other disease. Perfect rest does not mean that 
the patient should not be turned frequently, or that he 
should not have at times several pillows. It should be 
emphasized that the circulation in the lungs should be 
changed by alterations in position. A patient with 
pneumonia should not lie flat all the time. Hypostatic 
congestions readily occur with pneumonia, especially 
if the heart's action is impaired. 

The daily sponging for cleanliness should be gentle, 
and cause the least possible disturbance. 

2. Fresh Air. — It has now long been demonstrated 
that a pneumonia patient has less fever, a slower pulse, 
a better blood pressure, and breathes less frequently 
in cool, clean air than in close house air, and this 
whatever the season. Wards on the roof are very 
valuable for hospitals in the treatment of pneumonia 
as well as tuberculosis. The balcony, veranda, or even 
tent treatment of pneumonia is advisable at certain 
seasons of the year with certain types of patients, 
when such facilities are obtainable. It is always essen- 
tial that the room of a pneumonia patient should have 
more than one window — the more the better — and 
that these windows should be open, except when 
the patient is being bathed or his clothing is being 
changed. Under no circumstances is it wise to have a 
draft of cool or damp air blowing directly over the 
patient's face, but screens can modify the direction of 
the wind or brisk air. Very young children and old 
persons should not be subjected to severe cold atmos- 
phere, while older children and strong adults may not 
only endure cold, but may even thrive in it. The fresh 
air or outside air treatment of pneumonia is subject 



162 PNEUMONIA 

to the modification of common sense. If a patient's 
body and extremities become cold or chilled when 
properly covered, the fresh air treatment is too severe. 

3. Diet. — The food should represent something of 
all the elements required for nutrition. This means 
protein in the form of eggs, meat juices, properly 
made meat broths and milk. The eggs may be in any 
form desired, except fried. The milk should never 
be sufficient in amount to cause intestinal gas, or 
gastric indigestion. 

The next necessary element for nutrition is starch, 
and it should not be forgotten that many a seriously 
ill patient may die of acidemia from carbohydrate 
starvation. Egg albumin and milk do not represent 
the proper food for patients more than a few days. 
The starches can be presented in cereal gruels, rice, 
oatmeal, malted milk, toast, crackers, and even by 
potato soup. Ice cream, custard, chocolate, and a 
small amount of sucrose or lactose are all of value. 

The patient should be allowed plenty of water, as, 
however valuable a deprivation of water may be in 
aborting an acute cold or acute bronchitis, it is not 
advisable to withhold water in pneumonia. Unless 
there are edemas from a failing heart or from kidney 
insufficiency, water will increase the amount of urine 
and therefore remove more products of waste metab- 
olism from the blood, thus tending to prevent the 
toxemia which is to be feared. Water promotes the 
secretion of the skin, which is desirable, and also 
renders the exudate in the lungs less tenacious and 
more easy of expectoration. 

Elements of nutrition which must not be forgotten 
are: sodium chlorid, iron when meat juices are not 
given, and lime when little milk is given, and especially 
if there is much blood in the expectoration. The 
sodium chlorid can be given by properly salting the 
patient's food, especially his gruels, and even at times 
his milk. The iron may be given as a saccharated oxid 
of' iron, 3-grain tablet, crushed at the time of taking, 
or crushed by the patient's teeth, and administered 
twice a day. The lime may be given as lime water in 
tablespoonful doses in milk or in water, three or four 
times in twenty-four hours; or it may be given in a 
capsule as calcium glycerophosphate, in 0.3 gm. doses. 



THE DIET IN PNEUMONIA 163 

The whole question of the diet is also subject to 
common-sense modification to fit the patient. There 
are enough suggestions in the foregoing to furnish 
sufficient nutrition while meeting almost any patient's 
desires. The main object is (1) to avoid depriving the 
patient of any element that he requires to promote 
metabolism and keep up nutrition, and (2) to avoid 
gastric and intestinal indigestion. If the tongue is 
heavily coated and the patient is so seriously ill that 
he does not digest properly, 5 drops of dilute hydro- 
chloric acid in water, directly after his protein meals, 
will aid the stomach digestion and often clean the 
tongue. It may also stimulate intestinal digestion. If 
there is much intestinal gas, the diet should be closely 
studied to ascertain which food is causing it. Pro- 
vided the blood pressure is not too high, the heart not 
too irritable, and the patient not too nervous and rest- 
less, cofTee morning and noon, or coffee in the morn- 
ing and tea at noon, or tea both times if the patient 
prefers, is advisable and often beneficial. Tea and 
coffee should be considered as representing caffein, 
and if the action of caffein is desirable, these beverages 
may be given. They should not be given in the late 
afternoon or evening, as they tend to prevent sleep. 

4. The Bowels. — The bowels should move daily. 
Constipation should be prevented, but a diarrhea is not 
desirable. A cathartic may be given in the beginning 
of the disease, the one preferred by the physician. 
Later, his preferred laxative, whether a cascara mix- 
ture or some other combination, should be given. An 
occasional enema of glycerin and water, 1 ounce of 
each, will be found valuable. It will empty the colon 
and prevent the necessity of giving large doses of a 
laxative or a cathartic. Such treatment will aid in 
preventing tympanites. 

Diarrhea will weaken the patient and add one 
more element to cause weakness of the heart. If it 
occurs, the bowels should be cleaned out with a laxa- 
tive, castor oil if it can be taken, and then movements 
should be prevented by Y 10 grain of morphin. Saline 
cathartics are likely to increase the amount of gas in 
the intestine, and hence are generally contraindicated. 
Bismuth is likely to remain too long in the bowels and 



164 PNEUMONIA 

promote the growth of germs and the absorption of 
toxins, which will add one more danger in the pneu- 
monia toxemia that is constantly feared. Phenyl sali- 
cylate (salol) in 0.25 gm. doses, in capsules, may be 
given, four or five times in twenty-four hours, for a 
few days, to stop excessive fermentation. 

5. Abdominal Distention. — The routine use of a 
daily morning enema of soap suds has been suggested 
to prevent this complication. If abdominal distention 
occurs, milk should be temporarily eliminated from 
the diet. A napkin or gauze soaked in olive oil, 3 parts, 
mixed with turpentine, 1 part, may be applied to the 
abdomen. These should be covered with flannels 
wrung out in hot water, the heat being retained by 
covering with a thick pad. The hot flannels must of 
course be renewed frequently, as needed. These may 
be continued until relief occurs. Following the appli- 
cation of the stupes, medicated enemas may be 
employed. The following is suggested: 



Emulsion of 



Oil of turpentine 10 c.c. 

Asafetida 30 c.c. 

Soap suds 1000 c.c. (one quart) 



This is followed in an hour by an ordinary soap 
suds enema. 

Frequently pituitary solution 1 : 10,000 in doses of 
0.5 c.c. given hypodermically may be effective. 

6. Care of the Skin and Mouth. — It is rare, with the 
proper diet, the proper treatment of the bowels, and 
with plenty of fresh air, that the temperature in 
pneumonia is so high as to require sponging. Even 
when the temperature is very high, with a cere- 
bral complication, tepid sponging in a warm room 
is as severe treatment as should be tried. Ordi- 
narily, then, sponging once or twice a day with hot 
water is advisable, both for the comfort of the patient 
and to remove perspiration and keep the skin active. 
The temperature is more or less reduced by the warm 
sponging, the blood vessels of the surface are slightly 
dilated, the circulation is equalized, and the normal 
activities of the skin, which are essential, are increased. 
Also, warm sponging tends to relieve the tension of 
blood in the head, and many times aids in promoting 



SERUM TREATMENT OF PNEUMONIA 165 

sleep. If the patient's temperature is low, hot- water 
sponging is certainly advisable, and hot-water bags 
should be used around the extremities and even around 
the body. Profuse, cold, clammy perspiration should 
never be allowed to remain on the patient's body. 
Warm alcohol sponging in such conditions is advisable, 
that is, sponging with pure alcohol. A dash of alcohol 
in a basin of water has no therapeutic or physiologic 
value, and represents nothing but a fad. 

Cleanliness of the mouth, teeth and tonsils is very 
important. The patient may have infected himself 
from his own tonsils or his own gums ; such possibili- 
ties should be remembered, as well as the necessity of 
keeping the mouth as clean as possible during the ill- 
ness. 

The sputum, being as likely to communicate disease 
as is that from tuberculous patients, or even more so, 
should receive the same antiseptic care as does that 
of tuberculosis. The patient's mouth, excretions from 
the nose, and the nurse's hands and contaminated 
clothing or gauze should be treated in the manner so 
well understood in tuberculosis. 

Vaccines have absolutely no place in the treatment 
of pneumonia for any specific virtues which they may 
possess. They have been given in large dosage so 
timed as to secure the nonspecific protein reaction and 
some observers have reported markedly favorable 
results. The method is a dangerous one and there is 
as yet insufficient evidence to warrant its general adop- 
tion. 

SERUM TREATMENT 

As has been stated, workers in the Rockefeller Insti- 
tute have prepared antipneumococcus serums. The 
serums against infection with Type I organisms appear 
to have produced especially good results, and to be 
highly effective in the treatment of cases of pneumonia 
due to its type of organism. The serum of Type II is 
much less efficacious and, indeed, it has not yet been 
thoroughly demonstrated whether it has any valuable 
effect on the outcome of the disease. The serum for 

kType III organisms has apparently but slight thera- 
peutic power, and has not been considered worthy of 



166 PNEUMONIA 

of infections with Type IV pneumococcus. Commer- 
cial preparations of these serums are available and 
also polyvalent serums. These polyvalent antipneumo- 
coccus serums are of extremely doubtful value. It has 
been suggested that polyvalent serum be given until 
the type of the organism is determined, and that fol- 
lowing this, the specific serum for Type I or Type II 
may be utilized if the infection proves to be of that 
character. With pneumococci, at least as regards the 
first three types, the immunity reactions appear to be 
specific, and for this reason the workers in the Rocke- 
feller Institute do not advise the routine manufacture 
of polyvalent antipneumococcic serums. In fact, they 
suggest that for the present, the production of anti- 
pneumococcic serum should be confined to Type I. 
The first thing is to determine the sort of bacterium 
causing the pneumonia in the individual, and if it is a 
pneumococcus to determine the type to which it 
belongs. If it is a Type I pneumococcus, serum treat- 
ment may be undertaken. 

Before administering the serum, patients should be 
questioned as to previous injections of immune serums 
for diphtheria, meningitis or for tetanus infections, 
and also concerning previous symptoms suggesting 
asthma, hay-fever, or special sensitivity to proteins, 
including those in serum. It is well to try the 
intradermal skin test, injecting first 0.02 c.c. of 
sterile diluted horse serum, diluted with salt solution 
1 : 10, with injection of a simple salt solution as a con- 
trol, to learn whether or not the patient is especially 
sensitive to the serum. If sensitivity is present, the 
injection of the serum produces a large urticarial 
wheal surrounded by an area of erythema. 

It becomes evident when one views critically the 
present status of the serum treatment of pneumonia, 
that it can be properly carried out only in institutions 
where it is possible to make accurate bacteriologic 
diagnoses and differentiations of the types of pneu- 
mococcus, and where facilities for the intravenous 
administration of large amounts of horse serum with 
safety are at hand. Even at best a limited number 
of cases are suitable for treatment with immune 
serum, a large proportion of lobar and the very large 



DRUG TREATMENT OF PNEUMONIA 167 

group of atypical and bronchopneumonias not being 
susceptible of attack by these measures. 

Technic. — The serum is injected into a convenient 
vein, usually at the bend of the elbow, the skin being 
previously cleaned with iodm and alcohol. If there are 
facilities for making blood cultures, blood may be first 
withdrawn for this purpose. The serum is injected 
into the vein with a syringe, or by the gravity method, 
the injection being done steadily and slowly, the injec- 
tion of the first 10 to 15 c.c. occupying from ten to 
fifteen minutes. During this time the patient is care- 
fully watched for symptoms of reaction, such as 
increased rapidity of the pulse, difficulty of respiration, 
cyanosis or urticaria. If no symptoms arise, the 
remainder of the injection may be completed in from 
ten to fifteen minutes. 

Dosage. — The amount of serum necessary will vary 
in individual cases. It is generally believed that the 
initial dose should be large, perhaps from 90 to 100 
c.c. of the standard serum. The specific serum treat- 
ment having been begun, it should be continued until a 
definite favorable result has been obtained, and the 
serum may be given every eight hours in doses of 
from 90 to 100 c.c, unless there are contrary indi- 
cations. 

The average total amount of serum required in cases 
in the hospital of the Rockefeller Institute was about 
250 c.c. In many cases an elevation of temperature 
follows the injection of the serum within from twenty 
minutes to an hour, and this in turn is followed by a 
marked fall. If the temperature continues low and 
the patient's condition is good, no more serum is admin- 
istered. The temperature is taken every two hours, 
and if it rises within twenty-four hours to 102 F. or 
over, a second dose of serum is at once administered. 
If no fall of temperature occurs following the first 
dose, or if it does not fall to 102 F. within eight hours, 
a second dose of serum may be given. The same rule 
governs the administration of the third or subsequent 
doses. 

MEDICINAL TREATMENT 

We are past the stage when any dogmatic advice 
can be given in regard to the use of drugs in pneu- 



168 PNEUMONIA 

monia. The physician who has charge of a pneumonia 
patient must decide whether a drug is needed to com- 
bat a condition or symptom and which drug is the 
best for the object aimed at. The following are sug- 
gestions of drugs that have positive value for certain 
conditions, and brief descriptions of the pharmacologic 
action expected of them: 

Morphin or Codein. — If the pain is acute in the 
beginning of pneumonia, one of these sedatives should 
be given. Acute pain is depressant and should not be 
allowed. Strapping of the chest is inadvisable in pneu- 
monia. An ice bag over the painful region of the 
chest does not abort pneumonia and is generally not 
desirable, and on account of the generally high fever 
at this time, hot-water bags are not advisable. 

A cough that is frequent and unproductive, as it 
may be in the first stage of pneumonia, will be quieted 
and the pain alleviated by codein sulphate in doses of 
0.01 gm. (Yq grain) every two, three or four hours as 
is necessary. 

Acetanilid and Antipyrin. — Acetanilid, 0.1 gm. 
(2 grains) every three hours for four or five closes, 
or antipyrin, 0.5 gm. (7y 2 grains) every four hours 
for two or three doses, may be of advantage in lower- 
ing the high temperature in the first stage of this dis- 
ease. These drugs also will lower the blood pressure 
and quiet the heart. Such an action may be needed 
in the very acute first stage of pneumonia, provided 
the heart is normal. At this stage the lowering of 
the blood pressure produced by these drugs is often 
beneficial. Later in the disease, even if there is high 
temperature, such coal-tar products are contra- 
indicated. 

During the administration of the specific serum, 
drugs affecting the temperature should not be given, 
as the temperature is the best guide to the value of the 
serum, necessity for repeated dosage, etc. 

Ammonium Chlorid. — If the expectoration is very 
adhesive and cohesive, scanty in amount and hard to 
raise, ammonium chlorid acts satisfactorily and is indi- 
cated. The dose should be 0.25 gm. every two hours, 
given in a sour mixture, or in lemonade; and if there 
is much pain or if there is ineffective, frequent cough, 



DRUG TREATMENT OF PNEUMONIA 169 

it may be combined with codein sulphate. Ammonium 
carbonate, besides being irritant and nauseating, has no 
tangible cardiac stimulant action; therefore it should 
not be used. 

Digitalis. — If the patient does not die of the acute 
onslaught of the germ by incombatable toxemia, or by 
exhaustion from a later general toxemia, or from a 
migration of the pneumococci to the meninges, his sur- 
vival or death depends on the ability of his heart to 
withstand the disease. 

Porter, Newburgh and others have stated, on the 
other hand, that the heart muscle is not vitally injured 
in pneumonia. Respiration ordinarily fails before cir- 
culation. The heart in pneumonia may be influenced 
by digitalis in the same way as in normal persons, as 
shown by Cohn. The workers in the Rockefeller Insti- 
tute suggest the use of some form of digitalis as a 
routine in these cases. Its use should be commenced 
early so that the patient is partially digitalized when 
necessity arises. Large doses of an active preparation 
are given. When digitalis effects appear, the drug is 
discontinued as long as the patient's condition indicates 
that its use is not necessary. 

Strophanthin. — This drug, in recently made sterile 
ampules and injected directly into one of the veins 
in the elbow, provided digitalis has not been recently 
administered, is often efficient in tiding a patient over 
a shocked condition. It should rarely be repeated. 

Strychnin. — This is a drug that has been very much 
overused. Clinically, strychnin often does very good 
work and even seems to tide our patients over critical 
periods. In a sluggish, inefficiently contracting heart, 
when digitalis is contraindicated, strychnin may be of 
benefit. The rule for strychnin should be, when indi- 
cated as shown by this discussion, to give to an adult 
not more than % grain, hypodermically, if deemed 
advisable, once in six hours, and such a dosage should 
not be long continued. As soon as there is improve- 
ment, it should be given by the mouth instead of 
hypodennicallv. 

Camphor. — Laboratoiy findings and some hospital 
reports have not shown that camphor is of value in 
heart failure. On the other hand, clinical experience 



170 PNEUMONIA 

at the bedside not infrequently shows that hypoder- 
mic or intramuscular injections of a sterile preparation 
of camphor and oil improves the pulse as to its regu- 
larity and volume, causes the surface of the body to 
be warmer, and often relieve a cardiac dyspnea by 
thus equalizing the circulation. When there is cardiac 
dyspnea, when the pulse is small, and especially when 
it is slow and weak and the surface of the body is 
cold, and when there is cold perspiration, that is, a 
partial collapsed condition, camphor given hypodermi- 
cally every three or four hours may be of benefit. 

Caffein. — The administration of this drug as coffee 
or tea has already been discussed under diet. Perhaps 
no drug, except epinephrin, the action of which is 
very fleeting, so frequently raises the blood pressure 
in serious conditions as does, caffein. In emergencies 
it may be administered hypodermically, or it may be 
given by the mouth several times in twenty-four hours. 
It should not be forgotten that it is a cerebral stimu- 
lant and not a sleep producer. Its action on the heart 
is almost always for good, except in some few patients 
who show an idiosyncrasy to it, the heart becoming 
irritable from any form of caffein. 

Venesection. — In some cases with the right heart 
distended with blood, venesection gives great relief. 

Nitroglycerin. — When pneumonia occurs in a full- 
blooded, sturdy man, especially if he is of the age 
when his blood pressure is a little high, small doses of 
nitroglycerin, as % o t0 M.00 g r ain, every four to six 
hours, tends to dilate the peripheral vessels and relieve 
the internal congestion. It also slows and quiets the 
circulation. By bringing more blood to the surface of 
the body, it also tends to promote loss of heat and a 
reduction of* temperature. It will never weaken the 
heart as long as the blood pressure is high; it should 
not be used if the blood pressure is low. 

Hypnotics. — It is hardly necessary to name the dif- 
ferent hypnotics. As stated above, in very weak con- 
ditions the only safe hypnotic is morphin. In delirium 
and in insomnia it may be well to use some other hyp- 
notic than morphin. Almost any one of them causes 
some subsequent cardiac depression. The best hyp- 
notic is perhaps chloral, although there is a prejudice 



QUININE IN PNEUMONIA 171 

against its use. Probably an effective dose of chloral 
is no more depressant to the heart than is an effective 
dose of any other hypnotic. 

Quinin. — Based on a large number of bacteriologic 
and immunologic studies of pneumonia and the reac- 
tions of the infecting organisms to various agents, 
Solis-Cohen has become convinced that the drug, 
quinin, plays a specific antagonistic role against them. 
It is employed, he says, not to reduce temperature but 
to combat bacteria and bacterial poisons. The reduc- 
tion of the temperature which follows its use is used 
as a pharmacodynamic index. If the temperature is 
above 102 F. it is brought to or below that figure 
within three or four hours after the administration of 
quinin in sufficient quantity. A tendency to reascend 
is indication for more medication. By mouth he uses 
quinin dihydrobromid ; intramuscularly, quinin and 
urea hydrochlorid, and intravenously, either of these 
or the dihydrochlorid. To begin with, 25 to 35 grains 
are given by mouth, and later, according to effect, 5 
to 15 grains every two, three or four hours. Thus 
given, the temperature is kept down to 100 F. or below, 
careful watch being kept for symptoms of cinchonism. 
These are sweating, amblyopia or tinnitus aurium. 
Intramuscularly, 1 gram or 15 grains may be given and 
repeated every three or four hours. Intravenously, 
from 10 to 15 grains may be given in about 100 c.c. of 
physiologic sodium chlorid solution. While the drug is 
being given, solution of hypophysis may be used to 
sustain the blood pressure and prevent gastro-enteric 
paralysis. One c.c. of the posterior pituitary body 
extract may be injected every third hour until the sys- 
tolic blood pressure in millimeters of mercury exceeds 
by 5 points or more the frequency of the pulse in 
beats per minute. It is continued as long as needed in 
order to maintain this relation. 

CONCLUSION 

There is no specific cure for most cases of pneu- 
monia. The resources of the physician will be taxed 
and his judgment put to a severe test by many a case 
of this disease, but a successful outcome in many 
apparently hopeless cases will reward his efforts. 



172 RHEUMATISM 

As stated at the outset, a restful, quiet room, a sen- 
sible, efficient nurse, a sufficient amount of fresh air, 
and a suitable diet and proper care of the bowels will 
prevent high temperature, heart failure, low blood 
pressure, insomnia, tympanites and toxemia in very 
many cases, and prevention is far better than the treat- 
ment of these serious conditions. 

RHEUMATISM 

The term "rheumatism" is ordinarily applied to a 
group of symptoms chief of which is ill-defined pain in 
bones, muscles or joints. In a large series of cases 
studied by one author the etiology in individual cases 
varied greatly, some being due to syphilis, other to 
sciatica, neuritis, acute infections, tuberculosis and 
similar conditions. The patient with rheumatism 
usually presents a history of repeated attacks of acute 
or chronic tonsillitis or "sore throat." A thorough 
search will usually reveal one of these conditions or 
some other focus of infection in the body. Experi- 
mental work has shown and clinical experience has con- 
firmed the relation of these foci to joint disturbances. 
Numerous researches have been made on the blood, the 
muscles and the joints in these cases and various 
investigators have found streptococci which they 
believe to be specifically responsible for the attacks. 

TREATMENT 

If a focus of infection is found arrangements 
should be made for clearing it up and removing the pus. 
In acute cases, provided the focus of infection is in the 
tonsils, it may not always be advisable to remove the 
tonsils at once, but rather to wait for the patient's gen- 
eral condition to improve. Patients who are acutely ill 
should be handled as in other instances of acute infec- 
tion. The bowels should be moved at least every other 
day and perhaps more frequently if the patient's con- 
dition permits ; the mouth should be kept clean and all 
the phases of personal hygiene well attended to. 

It has been believed that the salicylates have a special 
effect in rheumatism and it has been customary to give 
them in large doses. Many physicians have reported 
favorable results following their use. Hanzlik and his 



PAIN IN RHEUMATISM 173 

associates made a comparative study of cases treated 
with and without salicylates. Their results indicate 
that the salicylates do not possess any unusual action or 
peculiar specificity it\ rheumatic fever. Prompt, though 
partial, relief was obtained in the majority of the 
patients receiving drugs other than salicyl. This was 
true for both early and late symptoms of the disease. 
In some patients in whom the symptoms persisted 
although considerably moderated, after treatment with 
nonsalicyl antipyretics and analgesis, salicyl appeared 
to give more permanent relief. Eliminating the ele- 
ments of time, rest, and natural recovery, relief of late 
symptoms was brought about more effectively and per- 
manently by salicyl than by combinations of drugs 
whose pharmacologic actions are similar, but different 
chemically. On the whole the salicylates must be con- 
sidered as a symptomatic remedy which can be admin- 
istered safely in large doses and which represents a 
fortunate combination of antipyretic and analgesic 
qualities making it more suitable and also desirable for 
the treatment of rheumatic fever than combinations 
of opiates and various antipyretics. As the salicylates 
in large doses may have an unfavorable action on the 
renal functions and the kidneys, they should be used 
with some slight degree of caution. 

The salicylates may be given in doses of from 5 to 
10 grains every two to three hours continuing the 
treatment for perhaps a week after the patient seems 
to be free from symptoms. At the same time potas- 
sium or sodium citrate are often valuable in keeping 
the system properly alkaline. Two grams (30 grains) 
three or four times in 24 hours for a time is generally 
sufficient for this purpose. 

Potassium or sodium citrate are often valuable in 
keeping the system properly alkaline. Two grams (30 
grains) three or four times in 24 hours for a time is 
generally enough. 

PAIN 

For the relief of pain a small amount of morphin is 
better than a large amount of a coal-tar product. This 
is always true when pain is constantly recurring. The 
repeated administration of any coal-tar preparation is 
inadvisable in acute conditions. 



174 RHEUMATISM 

The most important measure is immobilization and 
protection of the inflamed joints. Measures may be 
employed which increase hyperemia. 

The care of the individual joints which are inflamed 
cannot be dogmatically dictated. The joint and limb 
should be placed in the position that gives the patient 
the most comfort. If several joints of a limb are 
involved, and especially if there tends to be more or 
less troublesome muscle Contractions, or an inadvertent 
movement causes excruciating pain, a splint may be 
devised to keep the limb at rest. Warm, moist appli- 
cations, and perhaps nothing better than alcohol 
fomentations (one part of alcohol to 3 or 4 parts of 
warm water ; a towel or napkin soaked in this and then 
wrung out just sufficiently not to drip, and this wound 
around the joint and then covered with oil silk) will 
probably give as much comfort as any application. 
These should be changed as frequently as they are cold. 
Sometimes dry cotton around the joint causes as much 
comfort as any application. The official methyl 
salicylate may be applied, or oil of wintergreen, but 
probably neither is more valuable than the above 
alcohol dressing. Diathermy, cupping and various 
hyperemic treatments may be of value. 

The convalescence following rheumatism should be 
prolonged until the patient is thoroughly able to attend 
to his work. If there is a cardiac complication, pro- 
longed rest is positively necessary. It can never be 
determined how much endocardial inflammation was 
present, how much valvular inflammation and thicken- 
ing will be permanent, or how perfect the repair 
of the heart may be. Also, even when auscul- 
tatory evidence of cardiac complication has not been 
discovered, there may have been some inflammation 
which should call for prolonged rest. The adminis- 
tration of small doses of an iodid, best sodium iodid, 
from 0.10 to 0.20 gram (from iy 2 to 3 grains) three 
times a day, is often advisable. Such treatment has 
frequently seemed to hasten or aid in the complete 
recovery of endocarditis. Not every endocarditis from 
rheumatism leaves valvular lesions. 

Meat does not cause rheumatism, and prolonged 
abstinence from meat is generally inadvisable, still 



CHRONIC ARTHRITIS 175 

but a small amount of purin foods should be taken 
for some time. Eggs, green vegetables, and cereals 
should constitute the main food ; later, fish or meat 
once a day may be allowed. 

COMPLICATIONS 

Circulatory weakness during rheumatic fever may 
be combated with strychnin, with camphor, sometimes 
with caffein, and exceptionally with strophanthin. 

In the treatment of this disease, it should be urged 
that the heart be watched daily by stethoscopic exam- 
ination, to note as soon as signs of endocarditis occur. 
This complication is so insidious that it may not cause 
symptoms appreciable to the patient. There may, how- 
ever, be an increase of temperature, as there may be 
cardie pain or distress. While it is not the object here 
to describe the treatment of endocarditis, it may be 
stated that an ice bag over the heart may inhibit the 
inflammation, that the salicylates should be stopped if 
endocarditis occurs, and that rest and convalescence 
after complications should be prolonged. 

CHRONIC ARTHRITIS 

Chronic arthritis develops not only as a result of 
long continued bacterial infection but also on a basis 
of metabolic disturbances, gastro-intestinal derange- 
ment, etc. Bacteria may locally infect a joint and 
produce substances that are irritant. Mechanical 
injury to the joints whether irritation, pressure, 
overwork, or insufficient circulation from some old 
injury or anything that disturbs the nutrition of a 
particular joint or set of joints may become 
causes of chronic arthritis. The following locali- 
ties deserve attention as being the possible sources 
of toxins in such cases : the teeth, tonsils, naso- 
pharynx, bronchial tubes, bronchiectatic cavities, infec- 
tions of the gall bladder, appendix, seminal vesicles or 
fallopian tubes. 

TREATMENT 

Primary rest is necessary as long as motion causes 
pain. The etiologic factor must be sought and removed 
if possible. The metabolism of the patient should be 




176 CHRONIC ARTHRITIS 

studied thoroughly, and the analysis should include 
repeated examinations of the excretions. Worry, 
nervous frets and mental irritation should be avoided. 
In the treatment of individual joints, the measures 
mentioned under rheumatism should be borne in mind. 
Hyperemia about the joints may be produced and body 
baking may be of value in more generalized affections. 
In varying time, from four to six weeks, passive motion 
with gentle massage may be begun. The amount of 
passive exercise must be gauged by the effect on the 
individual. The patient, always more or less nervous, 
tires easily. To these patients tire is painful. Day by 
day the exercise must be increased. The rest, restora- 
tive measures (food, etc.), should improve the general 
nutrition and blood circulation. In due time active 
exercise is added. This must be systematically and 
regularly performed. Usually a nurse or masseuse 
should teach the patient the lighter forms of calis- 
thenics. These measures, namely: rest, restorative 
food, pure air, environment of optimism, graduated 
passive and later active exercise will overcome the 
debility, malnutrition and poor general circulation. 
Daily systematic passive and active exercises increased 
gradually must be continued until a relative restoration 
occurs. Otherwise a relapse is apt to occur because of 
neglect of one or more of the above important factors 
relating to nutrition, general and local blood supply, etc. 

VACCINES 

Autogenous vaccines made up of the dominating 
strains of streptococci obtained from the tissues and 
exudates of the focus of infection have been used but 
without any marked advantage. The general measures 
of management and treatment are absolutely necessary 
to succeed in helping these patients. To this manage- 
ment may be added autogenous vaccination without 
fear of harmful results. The use of vaccines in the 
treatment of chronic deforming arthritis without 
attempting to find or remove the dominating etiologic 
focus of infection and without a systematic hygienic 
management is irrational and most unjust to the 
patient. 



TREATMENT OF CHRONIC ARTHRITIS 177 
NONSPECIFIC PROTEIN INJECTIONS 

Several physicians have reported favorable results in 
these cases following the injection of nonspecific pro- 
teins, e. g., typhoid vaccine. In sub-acute and chronic 
cases of ostearthritis fifty million killed typhoid bacilli 
are given intravenously and if the reaction is only 
moderate the amount is cautiously raised at inter- 
vals of two or three days to a hundred and fifty 
million bacteria at an injection. It should be borne 
in mind that such methods have in them an ele- 
ment of danger and they should be utilized with 
due recognition of the possibilities. Moderately 
advanced heart and kidney diseases have not been con- 
sidered contraindications, but only as demanding care 
in the preparation of the patient: seeing that the 
stomach is empty for some hours before treatment and 
the use of a small initial dose gradually increased but 
only after all the disagreeable symptoms that previously 
existed from the last dose have passed away and 
appetite has returned. The immediate effects following 
injection are a more or less uncomfortable feeling 
accompanied by a chill, rise of temperature and emesis. 
Before forming any final judgment it will be well 
to bear in mind the question asked by Theobald Smith 
in another connection : how much energy does a reac- 
tion of this sort cost the patient, and is the final result 
worth the cost? 

MEDICINAL TREATMENT 

Medicinal treatment, except such treatment as is 
aimed to promote digestion, proper bowel activity, 
proper circulation, and proper character of the blood, 
is of little value. If there is thought to be hyper- 
acidity of the secretions or at least decreased alka- 
linity, alkalies may be of value, but certainly alkalies 
should not be pushed to the point of interfering with 
stomach digestion. Salicylates are of but little value 
in chronic joint disturbances. Iodids in large doses 
will produce waste, and may be what a fat patient 
needs. Small doses of iodid stimulate the thyroid to 
extra activity, promote general metabolism, and may 
be of value in the individual case. The use of radium 



178 ARTHRITIS DEFORMANS 

emanation has been suggested and reports are available 
indicating that it may relieve pain and to some extent 
arrest the disease but the results are not permanent. 
Colchicum in chronic arthritis is probably of little 
value except as it may increase intestinal activity. All 
of the various lithia salts, and all of the various laxa- 
tive and alkaline waters have no specific action, but if 
combined with increased muscular activity, increased 
activity of the skin, increased drinking of water in 
proper selected cases, a regulated diet and a regulated 
life, in other words, proper regime, they may be of 
apparent benefit. It is the regime, however, and not 
the particular kind of lithium or other salt that works 
the cure. 

ARTHRITIS DEFORMANS 

The etiology of this disease is only now being 
worked out. The relation of infection elsewhere in 
the body to this disease has been emphasized, espe- 
cially by Billings and cannot easily be overestimated. 
The changes in the joints are not due to the absorption 
of toxins from the focus alone, but to actual localization 
of the bacteria themselves. The difficulty in obtaining 
the causative organism is great, owing to chronicity; 
by special methods Rosenow succeeded in isolating 
peculiar streptococci from the excised lymph-glands 
draining the involved joints, from contracted and dis- 
eased muscles, and from excised portions of the 
diseased capsule of the joint itself, and recommended 
the use of a vaccine prepared from organisms thus 
isolated rather than from the streptococci in the focus. 
The use of even these vaccines, however, is quite futile 
unless the focus is removed. The peculiar character 
of the changes, in which there is a proliferation of 
endothelial cells in the blood-vessels about the involved 
joints with a consequent anemic necrosis, makes it 
clear that no matter what vaccine or other remedial 
agent is used, cure in advanced cases will be exceed- 
ingly difficult. Removal of the focus, the judicious use 
of autogenous vaccines in small doses prepared not 
from the focus but from the adjacent lymph-gland or 
tissue itself, together with rest, good air, passive 
motion and forced feeding comprise rational proce- 



ERYSIPELAS 179 

dures and yield substantial results. It is important 
to consider the special needs of each. In one instance 
important joints may have become ankylosed in 
unusable positions, or their motion interfered with 
by marginal exostoses. Appropriate surgical treat- 
ment will be of service in such cases. Other joints 
are benefited by immobilization with splints or adhesive 
tape. Continued infection, pain, and interference with 
locomotion may have resulted in partial invalidism, 
with attendant anemia, poor appetite and sluggishness 
of function of various organs of the body. With the 
removal of infection and all possible mechanical correc- 
tion of deformities should g% attention to nutrition by 
giving a well balanced general diet. Tonics containing 
iron may be of benefit. There is no drug therapy 
specific for this condition. The use of radium emana- 
tion has been suggested and seems to have a beneficial 
effect in some cases. Outdoor life and such moderate 
exercise as is consistent with the policy of rest for 
affected joints will help build up the general tone of 
the patient. 

ERYSIPELAS 
ETIOLOGY 

In the majority of cases of the facial type the point 
of entrance of the infection is through the nasal 
mucosa following a coryza. In others there may be 
abrasions of the scalp or face, and in many instances, 
the infection may begin in an operative wound. Leg 
ulcers and wounds are the usual origin of infection 
in the extremities. 

ONSET AND COURSE 

The attack usually begins with chills, general 
malaise, headache and a rise of temperature, which 
precede the appearance of the local lesion by from 
twelve to twenty-four hours. In many cases, however, 
the burning and redness of the skin are the first symp- 
toms noted. 

Typical facial erysipelas which starts at the bridge 
of the nose and spreads in butterfly pattern rather 
symmetrically over the cheeks, may remain thus 
limited, but in many cases it proceeds to involve the 



180 BOTULISM 

ears, the forehead, the scalp and the neck, down to 
but not beyond the collar-line, except in the small 
percentage of cases which are of the migratory type. 
In the migratory variety it often affects the extremities 
symmetrically. 

DIAGNOSIS 

The diagnosis is made from the characteristic skin 
appearance, the fever, bleb formation and desquama- 
tion. 

TREATMENT 

The treatment consists of a purgative; a low diet, 
mostly cereal; antipyretic measures, if required, a 
bromid sedative, if needed ; and later circulatory stimu- 
lation, if the heart fails. Meningeal complications must 
be watched for, and treated if they develop. 

On the affected part, continuous cold compresses of 
boric acid solution may be of value. In migratory 
cases ichthyol may be applied or the areas may be 
painted with picric acid solution. Silver solutions have 
been advised. Magnesium sulphate solutions are often 
efficient as a sedative lotion. Many times a starch 
powder dressing is all that is needed. 

BOTULISM 

This severe condition, fortunately rather rare, fol- 
lows the eating of food contaminated with the toxins 
of Bacillus botulinus, an organism whose spores are 
highly resistant to heat, and occurring usually in spoiled 
food. Careful investigations made by numerous pack- 
ing interests and also by the laboratories of the Uni- 
versity of California indicate that it occurs most fre- 
quently in home packed foods although undoubtedly 
authentic cases have occurred in commercially canned 
goods. Practically all kinds of packed foods have been 
affected including meats, vegetables, fruits, and most 
recently, ripe olives. 

PROPHYLAXIS 

Fortunately, food spoiled by Bacillus botulinus seems 
in most instances to have a cheesy odor, a bad taste 
and to be distinctly soft. These facts were frequently 
noted by those eating spoiled food, who, nevertheless, 



BOTULISM 181 

persisted in eating the food and became severely sick 
as a result. It has also been shown that less danger 
attaches to food which is well washed and thoroughly 
cooked, and these precautions in the way of cleanliness 
should be followed as a matter of routine in food 
preparation for the table. 

SYMPTOMS 

The first intimation of trouble in a large number of 
cases recently studied was an indefinite indisposition, 
followed rapidly by muscular weakness which gradu- 
ally increased to great prostration. There is constric- 
tion of the throat, difficulty in expectorating, thick 
speech, dryness of the mouth and dysphagia. This is 
apparently due to paralysis of the pharyngeal muscles. 
Swallowing becomes increasingly difficult and finally 
complete aphonia may develop. The eye symptoms 
are among the earliest manifestations. Dimness of 
vision, a blurring and mistiness are noted. Diplopia 
is one of the earliest symptoms. Ptosis of the eyelids 
develops and nystagmus may be seen. Vomiting has 
been seen in some cases apparently associated with 
large doses of the toxin which produce gastric irrita- 
tion. Patients who vomit at the onset seem to die 
earlier than the others. A feeling of pressure and 
weight at the pit of the stomach have been noted and 
also chilliness and profuse perspiration. The patients 
become drowsy and comatose immediately before 
death. Dyspnea manifests itself in difficulty of breath- 
ing. As the respiration weakens cyanosis appears. 

TREATMENT 

Even when seen relatively early there does not seem 
to be great success in the treatment of patients who 
have had considerable doses of botulinus toxin. Stimu- 
lants such as strychnin sulphate, atropin camphor in 
oil, digitalis and caffein have been administered. 
Inhalations of oxygen have been tried. Gastric lavage 
is performed as soon as possible. It is doubtful that 
cathartics can serve any useful purpose, but if the 
patient's condition permits it is perhaps as well to 



182 TETANUS 

encourage elimination from the system of the affected 
foodstuff ingested. The patients should be kept warm 
and treated symptomatically. 

Antiserums have been prepared and are available 
through the Hygienic Laboratory and will perhaps be 
made available through commercial houses. Dickson 
and Burke have shown that there are two definite 
strains of the botulinus organism and that antitoxin 
against one type has no affect in treatment when infec- 
tion is by the other type. The whole subject is in a 
state of active investigation and perhaps further 
research will yield something of specific value. 

TETANUS 

The incubation period of acute tetanus is from one 
to ten days, and of subacute tetanus from ten to 
twenty days. Fifty per cent, of all cases develop 
between the sixth and ninth day, the majority appar- 
ently on the seventh day after infection. Acute tetanus 
lasts from one to ten days, and subacute tetanus from 
ten to twenty days. Not until the patient has lived 
until the tenth day of the disease is there an equal 
chance for life. After the tenth day the patient's 
chances of recovery increase day by day. 

There is probably always more or less leukocytosis 
in tetanus, and Hill found the average count to be 
13,000. The eosinophils seem to be diminished 
in number. 

The tetanus bacilli is a cylindric rod, larger at one 
end than the other, and is an anaerobic germ. It is 
constantly present in the dirt of cities and on most 
country roads, as well as in barns and pastures. 
Noble has recently shown that this bacillus occurs in 
the intestines of otherwise normal animals, and he 
found the germ in the feces of eleven of sixty-one 
horses examined. Further examination of these 
infected animals showed that the germ could disappear 
in a few weeks, but could also remain present as long 
as four months. Such animals become tetanus car- 
riers, and are a constant menace to other animals 
which may receive injuries, and to their drivers and 



PREVENTION OF TETANUS 183 

hostlers, who may have slight wounds on their hands. 
These tetanus-carrying horses infect the dirt of the 
fields or streets on which they work or travel. 

This bacillus gains entrance to the system almost 
always through a wound or abasion, and, as has long 
been recognized, the most frequently infected wounds 
are contusions and crushing or lacerating wounds, 
especially those that occur from sliding, grinding and 
friction injuries in the streets and from lacerating 
wounds acquired in warfare, explosions, Fourth of 
July injuries, etc. At first the infection is a local 
one, and it is stated that the bacilli do not often wander 
from the point of infection; but they soon produce 
their toxins, which cause the general disturbance. 

SYMPTOMS 

The beginning symptoms of poisoning from this 
germ are aches and pains in the muscles, with a gen- 
eral lassitude, some headache, and soon some stiffness 
of the muscles of the back of the neck, face and jaw. 
The wound or source of infection may show no 
change ; in fact, may apparently be healed. The more 
or less permanent contraction of some muscles and 
the convulsions of tetanus are too well understood to 
need description. Spasm of the sphincters may make 
urination and defecation almost impossible. The mind 
generally remains clear, unless there is very high tem- 
perature, which is one of the causes of death. Death 
may occur during a convulsion from spasm of the dia- 
phraghm or spasm of the laryngeal muscles, or it may 
occur from exhaustion. 

I THE PREVENTION OF TETANUS 

For convenience the important points in the prophy- 
laxis may be summarized as follows : 
1. Carefully and thoroughly remove every particle 
of foreign matter from the wound, laying it open, if 
necessary, under anesthesia. 
2. Dry the wound thoroughly, and paint it and the 
surrounding parts as carefully as possible with iodin, 
or else cauterize it thoroughly with a 25 per cent, solu- 
tion of phenol (carbolic acid) in glycerin or alcohol. 



184 TETANUS 

3. Apply a loose wet pack, using a solution of some 
such antiseptic substance as boric acid or alcohol. 

4. As soon as possible inject intravenously or sub- 
cutaneously 1,500 units of antitetanic serum and con- 
tinue the injections, if indications of possible tetanus 
arise. A special committee appointed in Great Britain 
to study tetanus as it occurred in the war has recom- 
mended that in every instance four prophylactic injec- 
tions be given at intervals of seven days. 

5. In no case close the wound. Allow it to heal by 
granulation. Remove the dressings and packing each 
day and apply fresh ones. 

THE TREATMENT OF TETANUS 
ANTITOXIN 

The use of full doses' of antitetanus serum given 
as soon as the earliest symptoms appear is the measure 
of greatest importance in the treatment of this disease. 
The delay of treatment until the second or third day 
of symptoms, and the small doses (1,500 to 3,000 
units) go far toward explaining the failure of older 
methods to reduce the death-rate in this disease. It 
is important that the full effect of the antitoxin should 
be obtained immediately and this may be accomplished 
by giving 3,000 to 5,000 units intraspinally and 10,000 
to 20,000 units intravenously at the earliest possible 
moment after symptoms of tetanus appear. On the 
following day the intraspinal injection may be 
repeated. The blood remains strongly antitoxic for 
several days. On the fourth or fifth day 10,000 units 
should be given subcutaneously to maintain the anti- 
toxin content of the blood. If only a small amount of 
antitoxin (3,000 to 5,000 units) is available it should 
be given intraspinally. Intraspinal and intravenous 
injections should be given with all the precautions 
usually employed for these methods. Cases have been 
reported in which as much as 200,000 units of the 
tetanus antitoxin have been given intravenously, the 
condition of the patient indicating the need of the 
serum. 

Subsequent injections of antitoxin, especially when 
given intravenously, can cause anaphylaxis, sometimes 



DRUGS IN TETANUS 185 

severe; and Simon thinks that injections later than 
the tenth day become dangerous from the standpoint 
of being likely to produce anaphylactic shock. 

The prophylactic dose of tetanus antitoxin should 
be about 1,500 units, given subcutaneously, preferably 
in or about the region of the injury, and this should 
be given whenever the character of the injury or the 
region in which the injury is received presents any pos- 
sibility of tetanus infection. This dose can be repeated 
in a few, days if deemed advisable. 

As in administering diphtheria antitoxin, it should 
be ascertained if the patient is susceptible to emana- 
tions from horses or stables ; if he has hay fever 
and asthma symptoms from such emanations, it is 
unwise to administer horse serum, especially as a 
prophylactic for something that may not occur. 

This use of antitoxin in no respect replaces other 
necessary recognized non-specific methods of treat- 
ment in tetanus. Surgical treatment of the site of 
infection should be instituted at once. The patient 
should be placed at rest in bed in a quiet, darkened 
room, and should receive sufficient sedatives to con- 
trol convulsions, together with an adequate supply of 
fluid nourishment, and attention to the elimination by 
kidney and bowel. The necessity for large and con- 
tinued doses of chloral should not blind the physician 
to the possible danger of giving an overdose. 

OTHER DRUGS 

The serotheraphy by no means does away with the 
necessity for chloral or morphin. The dosage must 
be proportional to the age of the patient and the 
severity of the tetanus. Some clinicians give very 
large doses of chloral, but Permin thinks it is wiser 
to keep below the maximum dose and supplement the 
chloral with morphin, keeping the patient in a quiet, 
darkened room. It is of the utmost importance that 
the patient should get adequate nourishment as the 
resisting powers depend to such an extent on this. 
Fluid foods are best and with extreme lockjaw it may 
be necessary to resort to feeding through a nasal 
tube. 



186 ETIOLOGY OF MALARIA 

MALARIA 

Malaria, an infectious disease caused by the hem- 
ameba or Plasmodium malariae is a disease marked by 
chill, fever and sweating periods and by its response 
to quinin. While comparatively rare today in most 
parts of the United States it still takes large toll of 
the population in Italy, Russia and the tropics 
generally. 

ORGANISM 

The organisms are the tertian which requires 48 
hours for development and causes a paroxysm on each 
third day; the quartan, developing in 72 hours and 
causing paroxysms on each fourth day; the estivo- 
autumnal, irregular in development and causing the 
severer types of the disease. The organisms may be 
sought for in fresh blood on a warm stage, but if such 
is not available it is possible to detect them in dried 
or fixed specimens using Wright's, the Romanowsky 
or other common stains. 

' PREVENTION 

The notable work of the United States Army and 
Public Health Services have shown that this disease 
may be completely eliminated in any community by 
the proper measures. It is carried by the female 
anopheles mosquito. These lay eggs in marshy places, 
and from these eggs the larvae develop in warm 
weather after two or three days. The larvae are air 
breathers and are therefore easily destroyed by plac- 
ing petroleum on the surface of the water. Better 
still is the draining of marshes and breeding places. 
At the same time human habitations should be 
screened and while the work of draining and preven- 
tion is under way prophylactic doses of quinin should 
be administered to those likely to be affected. 

TREATMENT 

The general treatment of the patient with malaria 
should be that given to equally severe symptoms in 
other infectious disease. It includes bed rest (con- 
tinued through the interval periods of apyrexia) ; care 
of the diet, the bowels, the skin, etc. 



QUININE IN MALARIA 187 

During the chill the patient asks for warmth which 
should be given by the supplying of hot drinks in 
profusion, hot water bottles to the feet, warm cover- 
ings and similar measures. In the stage of fever the 
patient receives cool sponging, cool drinks, lighten- 
ing of the coverings on the bed, alcohol rubs and 
similar physical and hydrotherapeutic measures. If 
there is headache it may be relieved by cold applica- 
tions to the head or if intense by administration of a 
small dose of morphin. When perspiration begins 
the patient may be kept dry by rubbing with dry 
towels. Cooling drinks may be administered to aid 
in sustaining him. 

QUININ 

There are numerous methods of administering 
quinin to these patients and practically every physician 
who has treated these conditions extensively will 
describe special methods which he uses. 

Ochsner (Jour. A. M. A., March 17, 1917) 
describes a* technic of quinin administration with 
which hundreds of patients were cured in a com- 
munity in which he visited. Some of them had been 
deemed almost incurable as they had not yielded to 
other methods. He mentions first twelve facts which 
are to be borne in mind during the treatment as guides 
to the physician: 1. Quinin will kill the adult Plas- 
modium malariae. 2. Quinin will not kill the Plas- 
modium in spore form. 3. Quinin will prevent spores 
from developing into adult forms. 4. Quinin, if 
given continuously, will consequently keep malaria 
spores in the body, which will later cause a recur- 
rence. 5. Quinin must be absorbed in order to be 
effective. 6. Quinin must be kept constantly in the 
circulation, at least for forty-eight hours, in order to 
kill all plasmodia which belong to the one, two and 
three day type. 7. Quinin taken by mouth will not 
be entirely eliminated in three hours. 8. Quinin 
- taken by mouth may all be eliminated in six hours. 
9. It is consequently necessary to give quinin night 
and day at sufficiently short intervals to keep fresh 
quinin in the blood for at least forty-eight hours con- 
tinuously. 10. The alimentary canal must be in a con- 

------- 



188 MALARIA 

water in large quantity should be given with each 
dose of quinin in order to insure solution and absorp- 
tion. 12. The use of quinin should be completely 
interrupted for a sufficient interval after all adult 
Plasmodia have been killed to permit the spores to 
develop sufficiently to be killed by quinin, but not 
long enough to permit new spores to form; that is, 
the interval should be less than seven days. 

He then gives the following rules for treatment 
based on these facts: 1. Give an exclusive diet of 
hot soup for ten days treatment. 2. On the evening 
of the first day give 2 ounces of castor oil in fruit 
juice. 3. At 6 a. m. of the second day begin giv- 
ing a 2 grain capsule of quinin (preferably bisul- 
phate) with cover taken off, with one half pint of 
hot water, every two hours night and day for thirty 
doses, being absolutely sure not to miss a dose, in 
order to keep fresh quinin in the blood constantly. It 
is important to insist on waking the patient at night 
in order that the intervals shall not exceed two hours 
at any time. 4. The following six nights and five 
days give absolutely no quinin, but give a pill contain- 
ing 1/50 grain of arsenious acid, with one-half pint 
of hot water at 6, 9, 12, 3 and 6 o'clock. 5. Give 
castor oil as in Rule 2 on the evening of the fifth day. 

6. At 6 a. m. following the sixth night, again begin 
to give 2 grains of quinin precisely as under Rule 3. 

7. After that give general tonic and simple nourish- 
ing food. 8. Avoid reinfection by the use of screens 
and remaining away from locations where infected 
mosquitoes abound. 

Mayne and Carter working under the auspices of 
the United States Public Health Service have endea- 
vored to outline a standard form" of treatment which 
will insure the giving of a sufficient dosage of quinin. 
The greatest dereliction consists in the insufficiency of 
the dosage of quinin and the aborted length of treat- 
ment. The course of treatment provides for the appli- 
cation of a minimum of seventy-five days in the admin- 
istration of 800 grains of quinin bisulphate. For the 
first five days 10 grains of quinin bisulphate should be 
given four times daily. At the end of this period there 
should be no severe paroxysms, no chills, and only 



TUBERCULOSIS 189 

young rings and mature gametocytes in the blood. For 
the next ten days 5 grains of quinin bisulphate should 
be given four times daily. About the middle of this 
stage the patient, who should have been in bed, should 
probably be out of bed and clinically and apparently 
normal. With the exception of the gametocytes the 
parasites will not be demonstrable microscopically in 
the blood. The patient should then be able to resume 
his normal activities. For the next twenty days, how- 
ever, he may receive 2% grains of quinin bisulphate 
every four hours and arsenic in the form of Fowler's 
solution or some other tonic should be prescribed. 
Finally for a period of forty days 5 grains of quinin 
bisulphate should be taken daily with a tonic continued 
if the patient seems to require it. It is understood, of 
course, that the treatment is to be modified to suit the 
individual case — young adults or chronic cases in older 
persons — where the dosage indicated might not be 
wholly desirable. 

In cases of pernicious malaria, quinin may be given, 
in suitable preparations, intramuscularly and rarely 
intravenously. As there may be marked idiosyncrasy 
to quinin in some cases the intravenous method may be 
used only when it seems absolutely necessary and when 
previous inquiry has elicited the fact that there are 
no contraindications. 

TUBERCULOSIS 

Under the general title of tuberculosis are included 
the various pulmonary forms, abdominal forms, tuber- 
culosis of the bones, glands and other organs of the 
body. This is a disease of civilization and hence due 
to the congregation and crowding of mankind into 
small regions, as cities. Thousands of persons suffer- 
ing from pulmonary tuberculosis are walking our 
streets and expectorating billions of tubercle bacilli 
daily. 

ETIOLOGY 

The discovery of the tubercle bacillus by Robert 
Koch, in 1882, and the proof that this bacillus was the 
cause of tuberculosis, changed the established belief 
that tuberculosis was hereditary to the belief that it 



190 TUBERCULOSIS 

must always be acquired. This is of course a most 
constant fact, but the part that heredity plays in the 
development of tuberculosis, in furnishing proper 
ground in which the bacillus may grow, or in offering 
a condition of low-grade immunity against this disease, 
is progressively becoming more prominent. A human 
fetus can be born with tuberculosis, but comparatively 
few such cases have been recorded. If one were 
roughly to estimate the number of such authentic in- 
stances it might not be far from one hundred, and in 
most of these the mother was the tuberculous parent. 

Tubercle bacilli have rarely been found in the milk 
of an infected mother. Therefore, direct infection 
from this source is improbable. It is possible, how- 
ever, that toxins from the tubercle bacillus or from a 
secondary infection of the mother may be eliminated 
in the milk and cause, in the child, gastro-intestinal 
disturbance, fever and emaciation. It is improbable 
that the milk could furnish any substance that would 
render the child immune to tuberculosis. The thera- 
peutic conclusion is positive that a tuberculous mother 
should not nurse her child, not only for the child's 
sake, but also for her own, as the mother rapidly 
grows worse through the nutritional loss caused in 
producing the milk. 

Statistics show that the person who is underweight 
and has a family history of tuberculosis is more likely 
to develop the disease than one who is underweight 
without a family history of tuberculosis. On the other 
hand, a person of full weight or overweight, whatever 
the family history, while not precluded from the possi- 
bility of developing tuberculosis, is much less likely to 
have it than one who is underweight. Also, one who is 
underweight is more likely to develop tuberculosis than 
a person of normal weight. Whether or not, the 
majority of underweight persons harbor tuberculosis 
germs and such a condition predisposes to underweight 
has not been demonstrated, but it is quite possible. 

As is apparently true of most germ diseases, a race 
that has but recently acquired the disease is more sus- 
ceptible to its inroads, and has the disease more 
actively than a race that has long suffered from it. 
Also, a change from outdoor life and a dry, clean air 



ETIOLOGY OF TUBERCULOSIS 191 

environment to indoor or to city life, or to a region 
where the air is damp or dust laden, predisposes to 
the development of tuberculosis. 

These bacilli almost invariably gain entrance to the 
system by one of two ways : by inhalation, as occurs 
in the majority of cases, or by swallowing. A germ 
that is so constantly present in almost every com- 
munity of civilized peoples must be breathed and 
swallowed by most persons. Something in the in- 
dividual must tend to kill these germs before they 
acquire a home, that is, before they congregate in suf- 
ficient numbers to perpetuate themselves. Nothing 
probably tends more to prevent the acquirement of 
this disease than general good health, which especially 
means health of the upper-air-passages and throat, the 
absence of bronchial catarrh, healthy tonsils, a normal 
digestion and healthy intestines. The evidence that 
the tonsils may be a portal of entry Ravenel believes 
is very conclusive. The tubercle bacillus probably 
cannot find a living chance unless there is some dis- 
ease, injury or chronic disturbance in one of the parts 
of the body mentioned, and unless a sufficiently large 
number of them are inhaled or swallowed at once, so 
as almost to overwhelm the person's ability to destroy 
the germ. Of course, it is possible and perhaps prob- 
able that, although this disease gives no immunity, a 
patient in whom the disease has been arrested or in 
whom the disease once active is now chronic or more 
or less latent, may produce, or have already circulating 
in the body-fluids, enzymes that may destroy the 
tubercle bacillus more readily than is possible in one 
who has never had the disease. 

Perhaps many conditions that we have termed 
causes predisposing to tuberculosis may really stim- 
ulate to activity latent tuberculosis or a tuberculous 
focus harbored and concealed somewhere in the 
patient's body. Whichever of these two suppositions 
may be correct, we recognize that a patient is likely to 
acquire, or having acquired, at least may develop an 
active tuberculous process when he is anemic; when 
he is under weight; when he is continuously overfa- 
tigued; when he has a tendency to recurrent colds, 



192 TUBERCULOSIS 

especially to recurrent bronchitis; when he does not 
quickly recuperate from any simple acute infection, 
whether it be grip, measles or whooping-cough, etc., 
of when he has suffered from a more serious acute 
infection, such as some prolonged septic process or 
typhoid fever, and especially when he does not recover 
quickly from a pneumonia or a pleurisy with effusion. 
Pleuritic effusions are considered as perhaps generally 
tuberculous in origin. None of the surrounding pre- 
disposing causes, such as unsatisfactory housing- and 
occupations that are dangerously dusty, need to be con- 
sidered here. 

A child is considered predisposed to the development 
of tuberculosis, or perhaps already has a latent tuber- 
culosis, if he is pale, has a tendency to eczemas, or has 
enlarged tonsils or postnasal adenoids, and especially if 
he has enlarged cervical glands. Caries of the teeth is 
also perhaps a predisposing cause, as decayed teeth 
may harbor all kinds of germs. Therefore to allow 
caries of a child's first teeth to persist, because they 
will soon be lost with the eruption of the second teeth, 
constitutes serious neglect. An enlarged cervical gland 
probably always shows that an infection entering 
through the tonsil has invaded the next fortress 
of protection, namely, the cervical glands. If the 
infection is tuberculosis, the gland may be N actively 
tuberculous, and evident tuberculous adenitis is the 
condition. Much more frequent and not evident, but 
often found by good roentgenograms of the chests of 
children, is the involvement of the bronchial glands 
by the tuberculous germ having perhaps first gained 
entrance through the tonsils, and this without any 
involvement of the cervical glands. In fact, it has 
been repeatedly demonstrated that perhaps the major- 
ity of children affected with tuberculosis have the 
initial lesion in the tracheobronchial and hilus glands. 

The bovine tuberculosis is frequently transmitted to 
children through milk by way of the intestine has for 
some years been thoroughly established, and it has 
been shown that many instances of glandular tuber- 
culosis are due to this type of bacillus. General tuber- 
culosis rarely, but udder tuberculosis almost always, 



PROPHYLAXIS OF TUBERCULOSIS 193 

infects milk with tubercle bacilli. The frequency with 
which bovine-tuberculosis-infected milk causes tuber- 
culosis in children is still more or less a subject of 
dispute. Many experiments have shown that the gas- 
tric juice does not necessarily, if ever, kill the tubercle 
bacillus. 

MEASURES THAT WILL CAUSE A DECREASE IN THE 
INCIDENCE OF THIS DISEASE 

These may be enumerated as, primarily: 

1. General instruction in hygiene and in the con- 
ditions that predispose to this disease. 

2. Tenement-house laws to prevent overcrowding. 

3. Sunlight. 

4. Open windows, verandas and roof-gardens. 

5. Municipal breathing-spaces; parks, playgrounds, 
etc. 

6. Proper ventilation of all churches, theaters, halls, 
and assembly rooms. 

7. Open-air schools, or open-window schools. 

8. Laws prohibiting spitting on the streets and in 
buildings. 

9. Better factory sanitation; better methods of 
cleaning public buildings and public conveyances. 

10. Special laws against the dissemination of dust 
in factories, foundries and all occupations in which it 
may be inhaled. 

11. Better hygiene and improved buildings for all 
general hospitals, prisons and jails. 

12. Better laws for the more scientific control of 
tuberculous cattle, and compulsory cleaning and im- 
proving of cow-barns and farms used for producing 
public milk-supplies. 

13. Certification or pasteurizing of all milk used 
for infant-feeding. 

Personal preventive measures are : 

1. Compulsory report of every case of tuberculosis. 

2. Careful instruction of the family in the care of 
the tuberculous person, if he is to remain at home. 

3. Careful personal instruction of the patient, if he 
is at an age to receive it, as to the possible methods of 
communicating the disease to others. 



194 TUBERCULOSIS 

4. Sanatoriums for incipient cases of pulmonary 
tuberculosis. 

5. Isolation hospitals for advanced tuberculosis 
patients whose home surroundings are inadequate. 

6. Skilled dispensary care of ambulatory cases and 
visiting nurses for "follow-up" work. 

7. Sanatoriums or rest-hospitals for joint and bone 
tuberculosis ; these are of special value when located 
at the seaside. (The value in glandular tuberculosis of 
seaside sanatorium or veranda rest-cures should also 
be recognized.) 

8. Careful instruction to reduce the morbid fear of 
other members of the family, and for the mental com- 
fort and happiness of the patient. This should be 
given, both by the board of health and by the attending 
physician, to the effect that the disease is not contagi- 
ous, and that if the instructions urged are properly 
carried out the probability -of acquiring the disease 
from the patient is practically nil. 

9. It has long been known that pregnancy in a tuber- 
culous woman is a dangerous complication. Though 
she may appear to have better health during the 
pregnancy a fatal issue may follow rapidly after par- 
turition. Knopf and many others who have recently 
considered this subject believe that there should be a 
maternity sanatorium or special wards in existing 
sanatoriums where prolonged antituberculous treat- 
ment may be given to the tuberculous women who 
wish to bear children. 

PRETUBERCULOUS SYMPTOMS 

The earlier we recognize the signs of probable or 
even possible tuberculosis, the better, as prevention is 
far easier than cure, though a cure is probable all 
through the first and second stages, and possible even 
in the third stage of the disease. 

The conditions which predispose to this disease have 
already been enumerated. Besides correcting these 
conditions, we should use every means to build up the 
general system by tonics, outdoor life, change of clim- 
ate, and by proper tepid or cold water sponging in the 
morning which causes the skin so to react that colds 
are not readily acquired. 



PRETUBERCULOUS SYMPTOMS 195 

At a very early stage there may be no lung signs, 
and it may be impossible to determine whether or not 
the bronchial lymph-nodes are enlarged or diseased. 
There are loss of weight, more or less gastric disturb- 
ance, pallor, lassitude and vasomotor disturbances 
shown by cold hands and feet; or the latter may be 
intermittently very hot and dry. There is generally 
a history of progressive loss of weight, irregular chest 
pains, shallow breathing, dry cough, especially on deep 
inspiration, and, most important symptom of all, an 
afternoon or evening rise of temperature, not explain- 
able by any tangible cause (although it must not be 
forgotten that occasionally such a temperature can be 
of nervous origin). Gastric indigestion, with loss of 
appetite, is often an early symptom of pulmonary 
tuberculosis. An anal fistula is generally secondary, 
and is not often primary to the lung lesion, and the 
discharge from it may contain tubercle bacilli, as well 
as staphylococci and streptococci. There may be some 
other chronic suppuration present, as a middle-ear 
catarrh. While anemia is generally an early symptom, 
in the early stages there may be an increase in the 
number of the red-blood corpuscles. Amenorrhea, 
even without anemia, in girls and women is generally 
an early symptom; but women can complete one, or 
even two pregnancies while tuberculous. 

While we are studying every symptom, and the 
lung symptoms are so few, to ascertain whether the 
patient really is tuberculous, a personal history of 
much sickness, especially colds, enlarged glands, 
chronic joint and tendon swellings or recurrent 
diarrheas, even if there has been no actual pulmonary 
consumption in the immediate family, renders the 
tendency, and hence probability of tuberculous infec- 
tion, much greater. 

In making the physical examination it should be 
remembered that it has long been decided that the flat, 
broad chest, contrary to previous belief, is less likely to 
be tuberculous than the rounded, barrel-shaped chest. 
Also, the chest circumference in the nipple line should 
measure anatomically half the height of the person. 
The expansion, unless the patient is abdominally 
obese, should be from 2% to 4 inches; 2 inches, 



196 TUBERCULOSIS 

though accepted by army requirements, is a very 
small expansion for a young adult. The inspection 
of the chest may show a lagging of one side dur- 
ing expansion, which may, however, be most notice- 
able with the finger-tips placed under the clavicles. 
This sign is very suggestive. The typical impaired 
percussion-note, imperfect breeziness of the inspir- 
atory murmur, lessened depth, slight jerky inspiration, 
slightly prolonged expiration, slightly increased vocal 
resonance and localized rales, either dry or moist, with 
increased muscle resistance over a diseased area, with 
pleuritic pains in the upper part of the chest or be- 
tween the shoulder-blades, are all too well understood 
to require elaboration. Very suggestive is the axillary, 
dripping perspiration during examination. Also sug- 
gestive is the little dry cough during the required in- 
creased inspiratory effort. This dry cough, hardly 
noticed by the patient, has probably been observed for 
weeks, if not longer, by the patient's family. 

A study of the temperature of the suspected person 
is important; the temperature should be taken every 
three hours during the day for several days, or at least 
at 8 o'clock in the morning, at 4 in the afternoon, and 
at 8 in the evening, if not more frequently. A recur- 
rent rise of temperature in the afternoon or evening, 
without any assignable cause, is almost pathognomonic 
of a latent tuberculosis becoming active. Some patients 
who show no temperature at rest will have quite a rise 
of temperature on the least exercise. Temperatures 
taken under the tongue are not so accurate as when 
properly taken in the axilla. Many a patient whose 
temperature is normal by the mouth will be found to 
have a higher temperature in the axilla. Of course, 
the most accurate is the rectal temperature, but this 
is rarely necessary for the diagnosis. An increased 
pulse-rate, over a hundred, with or without rise of 
temperature, is very suggestive, and if the pulse- rate 
is higher than the temperature would call for, the like- 
lihood of tuberculosis is increased. 

A slight hemorrhage of arterial blood always 
causes the laity to suspect phthisis, and the suspicion is 
quite generally correct. Hemorrhages can occur from 
the blood-vessels of the throat and larynx, although 



SYMPTOMS OF TUBERCULOSIS 197 

they are generally very small in amount, and most f re^ 
quently venous, and many a patient has been con- 
demned to treatment for tuberculosis on account of a 
perfectly simple throat hemorrhage. 

The occurrence of typical night sweats, that is, cold 
sweats toward morning, is a frequent and suggestive 
symptom of tuberculosis; but patients who have been 
weakened by illness, overwork, or overexertion may 
have this symptom for a short time, although it should 
always create suspicion. 

A rarely noted symptom of tuberculosis, which may 
occur early in the disease or not until later, is atrophy 
of the mammary gland on the affected side; also, the 
hand and foot may be colder on the side affected, or 
if they are hot and dry, may be warmer than on the 
other side of the body. Conjunctivitis, blepharitis and 
an inequality of pupils, with dilatation of the pupil on 
the same side as the affected lung, have been noted. 
The skin of the tuberculous patient is often dry, and 
may be rough and sallow; there may be increased pig- 
mentation, especially around the nipple on the diseased 
side, and there may be chloasmic spots. Bright red 
spots on the cheeks, and the glistening eyes occurring 
in the late afternoon, with tne hands dry and hot, are 
almost pathognomonic. At other times of the day 
there is pallor, with the veins prominent all over the 
body; the face looks sad, and there is languor and a 
rapid, collapsing pulse. These are all signs that may 
occur at an early period. 

Before deciding that the sputum qf a suspected 
patient, or a patient who has incipient tuberculosis, is 
free from tubercle bacilli, several examinations must 
be made. The sputum may be found free from bacilli 
on several days, and then on the last day of the exam- 
ination found to be loaded with them. The number of 
bacilli found has no great bearing on the prognosis of 
the disease. On the other hand, if large numbers of 
tubercle bacilli continue to be present after consider- 
able periods, probably cavitation is either present or 
developing. The prognosis can hardly be made from 
the character or appearance of the tubercle bacilli, 
although it has been thought that large numbers of the 
smaller tubercle bacilli show greater activity of the 
disease. 



198 TUBERCULOSIS 

A fluoroscopic examination of the chest will often 
reveal, even before clouding of any portion of the lung 
occurs, a diminished excursion of the diaphragm on 
the affected side. This is very suggestive of tubercu- 
losis. Roentgenograms may show areas of beginning 
lung trouble as well as diseased bronchial glands. Be- 
sides the skin tuberculin tests, the conjunctival test and 
the interdermal test, all of which are more or less 
reliable, a positive diagnosis can generally be made by 
injecting the original tuberculin subcutaneously. 

A number of substances can produce a reaction in 
tuberculous patients similar to that from tuberculin. 
Nucleoproteins, cinnamic acid and some alkaloids can 
do this. 

The tuberculin used in making the test for tubercu- 
losis is a purified extract prepared from tubercle 
bacilli. The details of its preparation need not be 
described here. Its injection causes a leukocytosis 
and stimulates the production of ferments, especially 
in the cells and tissues immediately surrounding the 
tubercles. These ferments then act on the poisons that 
have been produced by the tubercle bacilli and have 
accumulated in the tubercles. 

The fever reaction is due to the toxins set free from 
the tubercles and to the action of the enzymes on these 
toxins. If some form of tuberculin is used for cur- 
ative purposes, the reactions will become less and less, 
as more of these sealed-in toxins are set free. Also, 
reaction may be less as the system becomes less sensi- 
tive and hence immune to the irritation of these toxins. 
It can readily be seen that if too large doses of tuber- 
culin are administered either as a diagnostic test or as 
a curative treatment, such a large amount of these 
toxins might be liberated as to cause an intense fever 
reaction, to the disadvantage of the patient. Also, it 
is quite possible by such treatment to liberate live 
tubercle bacilli and cause general infection. Hence the 
greatest possible care should be exercised in using 
tuberculin, either as a test or as a treatment, and the 
first doses should be of minimum amounts. 

As tubercle bacilli are not readily killed by leuko- 
cytes, the latter surround the mass of bacilli and disin- 
tegrating and caseous material ; the resulting lesion is 
called a tubercle. The fight, then, of enzymes and 






TUBERCULIN TESTS 199 

toxins goes on between the two opposing factions. 
Some of the leukocytes and some of the bacteria die, 
with the production of toxins and enzymes. If these 
are liberated by the local inflammatory process the 
fever reaction and the other concomitant symptoms 
occur in the person if sufficient amount of the toxin 
circulates in the blood. Every tubercle that breaks 
down and is evacuated into the bronchial tubes and 
expectorated, is a step toward recovery. This satis- 
factory process, however, cannot go on without a 
general disturbance of the patient, "with loss of appe- 
tite, loss of weight and emaciation, and it becomes a 
question whether the person can stand the disease until 
the tubercles are evacuated, and whether or not such 
evacuation will produce cavitation. The object of a 
tuberculin treatment is to aid the patient slowly to 
eliminate his tubercles when the disease in him has 
come to a standstill, and he shows no tendency to re- 
covery, even if he is not growing worse. The theo^ 
retical object, then, aimed at by treatment is the 
elimination by the patient of most of the tubercles, or 
the permanent encapsulation of those not eliminated 
by such fibrous and calcareous material as will cause 
them to be forever outside of the body, as far as 
any relationship to the blood and lymphatic circulation 
is concerned. On the other hand, if too many 
tubercles are broken down at once, too persistently or 
too continuously, the prognosis is bad, and tuberculin 
is ordinarily not indicated. 

Our conclusions as to the subcutaneous tuberculin 
test may be as follows: 1. It is a reliable test, and is 
pathognomonic in children and young adults. In older 
adults, if the test is positive, it may be relied on as 
showing a tuberculous focus somewhere, but if the 
test is negative it is not so reliable as in children. 2. 
It should not be used carelessly, though perfectly safe 
if the beginning dose is small. 3. The tuberculin test 
is unnecessary when a localized pulmonary lesion has 
been discovered by physical examination. 4. When 
we recognize that a patient is tuberculous or is liable 
to become so, although we find no physical lesions, the 
tuberculin test is unnecessary, as our preventive 
treatment should be the same whether reaction is posi- 



200 TUBERCULOSIS 

tive or negative. 5. In doubtful bone, tendon or joint 
inflammations, or when for any reason a decision must 
positively be made, the tuberculin test should be used. 

Although a reaction from tuberculin has occurred in 
Cases of carcinoma, syphilis and actinomycosis, still, 
these instances are so rare that there is the probability 
that such patients had a latent tuberculosis, and hence 
the test may be considered positive. In advanced cases 
of tuberculosis, however, the test may be negative or» 
account of a tolerance to the toxins already described. 

The beginning dose of "old tuberculin" for diagnos- 
tic injection is 0.1 mg., the second dose should be 1 
mg., the third may be 3 mg. and the fourth 5 or6'mg. 
Of course, a reaction occurring with any dilution 
would prevent the necessity or advisability of giving 
another injection. A suspected patient not reacting to 
5 or 6 mg. should be considered free from tuberculosis. 

If a physician desires, he may receive direct from 
the serum and bacterin firms the "old tuberculin" 
properly diluted for the diagnostic test. 

The tuberculin injection test should be used only 
with a patient who is at rest and does not have a morn- 
ing rise of temperature as shown by a series of ob- 
servations. The injection should be given at about 9 
p. m., and if there is a rise of temperature in the early 
morning, it should be considered a positive reaction, 
and if there is pain, swelling or heat discovered at an 
external suspected area, as a joint, or if there is con- 
gestion or moist rales are discovered in a suspected 
area of lung-tissue there is a "focal reaction." If 
there is a marked reaction at the region of the injec- 
tion (the "local reaction"), even if there is no general 
reaction, the patient probably has tuberculosis, and it 
may often be unnecessary to continue the injection of 
higher dilutions. 

The "intradermal" tuberculin test for the diagnosis 
of latent or concealed tuberculosis is now frequently 
used. The advantage of this test over the von Pirquet 
and the Moro skin tests is that a known amount of 
tuberculin is injected between the layers of the skin. 
The reaction is a local one, and there is no general 
disturbance like that occurring with the subcutaneous 
tuberculin test. 



DRUGS IN TUBERCULOSIS 201 

GENERAL MEDICATION IN THE TREATMENT OF 
TUBERCULOSIS 

In the first place, drugs, as such, cannot cure, and 
are not antidotes to this disease. On the other hand, 
much can be done, with proper medication, to aid the 
physiologic process. 

Calcium. — It has long been thought that patients 
suffering from tuberculosis have previously become 
demineralized. This means especially that they have 
lost their calcium, and perhaps phosphorus, equilib- 
rium. It is also true that tuberculous lesions heal by 
more or less calcification. Also, patients are more 
likely to have hemorrhages, if their calcium blood- 
content is diminished. Certain it is that patients, 
especially children, often improve with increased 
amounts of calcium in their food or as a medicament. 
One of the great values of a proper amount of milk 
for tuberculous patients is probably the calciunvand 
phosphate content. On the other hand, many patients 
improve by the administration of a calcium salt. 

Creosote. — Creosote has been long recommended 
and much used, and its action in tuberculosis has been 
lauded by able medical men. 

There is a great difference of opinion among clin- 
icians as to the value of creosote in pulmonary tuber- 
culosis. Many physicians never use it in this disease, 
and others push it to such an extent that the patient is 
practically saturated with it, and his room and almost 
the whole house reeks with the odor of creosote. It 
seems to be true that many patients have improved 
appetite under its stimulant or irritant action in the 
stomach. It may also, for a time, improve digestion, 
and the patient often adds weight. During this period 
there is frequently a lessening of the bronchitis, and 
therefore a decreased expectoration, and with this 
decrease of the secondary (streptococcic) infection, 
there is likely to be less fever and therefore less sweat- 
ing. It is so rare, however, for a patient to take creo- 
sote and not adopt the rest cure and other measures 
that go toward improving his condition that it is not 
fair to attribute such improvement to the creosote. 
Creosote is also more or less of an intestinal antisep- 



202 TUBERCULOSIS 

tic, and hence bacteria-laden sputum that may be inad- 
vertently swallowed may be rendered harmless in the 
upper part of the intestine. Be that as it may, it is 
a fact that good bowel activity, an improvement in the 
intestinal digestion, and the prevention of fermentation 
or putrefaction in the intestine, by many so-called 
bowel antiseptics, will all cause an improvement in the 
tuberculous patient; 

Unfortunately, as frequent aftermaths of the good 
action of creosote the pancreas becomes overstimu- 
lated by the drug and does not furnish its secretion 
properly; there is intestinal indigestion; the liver is 
disturbed; there are stomach indigestion and loss of 
appetite, and the patient will lose weight faster than 
he gained it under the creosote treatment. Too much 
creosote will also irritate the kidneys, and may cause 
albuminuria. In other words, it generally does not 
seem wise to recommend creosote, as such, internally 
in pulmonary tuberculosis. As an ingredient of an 
inhalant mixture it may be of value, as a positive anti- 
septic to the upper air-passages and the trachea and 
large bronchial tubes. If there is fetid, purulent ex- 
pectoration such inhalations may be of advantage. 

Guaiacol frequently in the form of a benzoate of 
guaiacol has been used for tuberculosis, but guaiacol 
has no advantage over creosote in the treatment of 
tuberculosis. The exponents of the creosote treatment 
believe that the drug should be begun in small doses 
and gradually increased to the point of the patient's 
tolerance. Tolerance means that the appetite is not 
interfered with, that there is no nausea or vomiting, 
and that the urine does not become dark and show 
albumin. 

The symptoms of creosote poisoning are similar to 
phenol poisoning. From its overaction the patient not 
only has gastritis and intestinal disturbances, but also 
dark urine (perhaps nephritis), dizziness and sweating. 

Cod-Liver Oil. — This oil is a food, and as such has 
its advantages. A small dose of cod-liver oil is as 
easily taken as a large dose of some emulsion which 
contains but little of the oil. In other words, if one 
desires to give cod-liver oil, it may be given; but, as 
previously stated, other oils and fats are often of as 



DRUGS IN TUBERCULOSIS 203 

much advantage, particularly butter, and it certainly is 
not wise to load the system with large amounts of bile- 
salts. There is no difference in the effect of Nor- 
wegian cod-liver oil and the oil prepared on our own 
shores. 

The Hypophosphites. — There is no chemical, physi- 
ologic or specific excuse for giving the hypophosphites ; 
the success of treatment of lung conditions with hypo- 
phosphites is a fallacy. It is not intended to state that 
some phosphorus and some calcium-bearing prepara- 
tions and foods containing these elements may not be 
of value, but one is not justified in expecting results 
from any hypophosphite combination of these or other 
elements. 

Arsenic. — Arsenic has been advised for years in 
many lung conditions. It has been stated that the 
arsenic eaters of France and Switzerland have been 
more or less immune from tuberculosis. It has been 
stated that patients breathe more freely and better un- 
der the influence of arsenic. However this may be, 
in the treatment of pulmonary tuberculosis the value 
of arsenic is very slight. It seems to stimulate the 
production of blood-corpuscles, both red and white, 
and in small doses it may stimulate the appetite. In 
large doses arsenic is harmful, as it tends to cause 
destruction of red blood corpuscles, to irritate the kid- 
neys, to upset the digestion, and when pushed, may 
cause multiple neuritis. In other words, arsenic is a 
poison, and should not be administered to a patient 
unless there is a tangible, positive indication. 

Iodm. — For many years this element in some form 
has been given frequently for various kinds of tuber- 
culosis, especially glandular tuberculosis. As the thy- 
roid is generally disturbed in tuberculosis, iodin in 
small doses may be of benefit. 

Harm has been done in pulmonary tuberculosis 
by the administration of an iodid. It seems to be 
a stimulant to the tubercles, not unlike tuberculin, and 
may cause a lighting up of a quiescent tuberculous 
process or a serious exacerbation of a slow-going in- 
fection. The stimulant action on glands is well known, 
and tuberculous glands may be overstimulated to the 
harm of the patient. In other words, iodids should not 



204 TUBERCULOSIS 

be used carelessly in pulmonary and glandular tuber- 
culosis. This does not militate against the possibility 
of small, very slowly increasing doses of iodin doing 
the same good that graded doses of tuberculin do, but 
the treatment should be most carefully watched. 

Chemotherapy. — The success of salvarsan in syph- 
ilis has stimulated similar experiments with regard to 
tuberculosis. These include the use of methylene blue 
and compounds of arsenic copper, various dyes and 
other substances. Most prominent has been the work 
with cyanocuprol by various Japanese investigators 
and most optimistic claims have been made for this 
substance. None of the numerous substances studied, 
however, as yet warrants the hope that a specific treat- 
ment has been found. Certainly these drugs should 
not be tried in the human until they have been thor- 
oughly tested by the usual experimental methods. 

Tuberculin. — Tuberculin is not in itself curative, but 
it is, at most, a stimulant to the curative efforts of the 
organism. Many observers are of the opinion that it is 
of value in selected cases of tuberculosis. The potency 
of tuberculin for harm is recognized by all. Its admin- 
istration requires careful selection of the case, close 
observation of the patient and appropriate regulation 
of the dose. Patients should be treated in a hospital, 
or, if the remedy is administered to ambulant patients, 
a strict control should be exercised. The results are 
frequently good in the forms of localized tuberculosis 
called surgical, such as affect the skin, bones, joints, 
lymph-nodes and larynx. Tuberculosis of the lungs, 
when strictly localized, would appear to indicate its 
use, but the different character of the tissue involved 
seems to render the results less favorable. 

Heliotherapy. — Treatment by the direct rays of the 
sun has been applied by Rollier of Leysin, especially 
in cases of pulmonary tuberculosis complicated by 
local tuberculosis of the bones, joints or glands. It is 
being used more and more in ordinary cases of pul- 
monary tuberculosis. It should be applied with cau- 
tion, where there is fever or a tendency to hemoptysis. 
It consists in graduated exposure of the body to the 
light of the sun for increasing periods daily until the 
resistance developed permits a long stay in the open 



SUNLIGHT TREATMENT OF TUBERCULOSIS 205 

air. The treatment is said to be well borne by chil- 
dren. During the treatment the head should be pro- 
tected and the room should be comfortable for the 
patient. 

Gauvain (Brit. Jour. Tuber c, 1916, 10, 111) believes 
that sunlight is an important adjunct in treatment of 
tuberculosis. He summarizes the action of sunlight 
as follows : On the local lesions it has at first a direct 
effect. Superficial micro-organisms are destroyed or 
inhibited by the sterilizing action of the light waves, 
and this action is assisted by the inflammatory re- 
sponse which results from a reasonable exposure to 
strong sunlight. The author has formulated a number 
of rules which must be observed when this treatment 
is given: 1. The patient's head must always be pro- 
tected. 2. The patient must never be allowed to 
become too cold or too hot. 3. On the first day the 
legs to the knees may be exposed hourly for five min- 
utes. If this is tolerated well, exposure of the knees 
may last for ten minutes hourly. On the third day 
exposure of the thighs for ten minutes hourly, and 
on the fourth day, similar exposure for fifteen minutes 
may be attempted. On the fifth day exposure of the 
thighs for fifteen minutes and of the body for five 
minutes is desirable. On the sixth day exposure of 
the thighs for fifteen minutes and of the body for ten 
minutes hourly may be attempted. If the patient is 
pigmented, the periods of exposure may be gradually 
increased, until the patient may be completely exposed 
for periods, and, when pigmentation is fully estab- 
lished, continuous exposure may be undertaken. 4. 
Blistering must be carefully avoided. 5. If the tem- 
perature exceeds 100 F., the patient should not be 
exposed the following day, unless special orders are 
given. 6. Sinuses should be exposed and any puru- 
lent discharge from them should be immediately 
swabbed. 7. A nurse must be on duty during the 
whole time. 

TREATMENT OF SYMPTOMS 

Fever. — Nothing tends to diminish the temperature 
more than the rest, quiet and fresh-air treatment 
already outlined. The patient who has high fever 



206 TUBERCULOSIS 

should not be given too much food at any time of day, 
even if the disease is tuberculosis; and most of what 
he does receive should be given during an afebrile 
period, if possible. If he is suffering from acute tuber- 
culosis, the nutrition should be much the same as for 
any other serious fever. 

Sponging with hot water will often give these pa- 
tients comfort and, if they have profuse sweats, it 
keeps the skin clean. The frequency of such sponging 
will, of course, depend on the height of temperature 
and its continuance. Antipyretics are rarely indicated. 
The following points should be observed in the treat- 
ment of fever: First and foremost, absolute rest in 
bed, preferably out of doors; artificial pneumothorax 
in selected cases; the cautious use, if at all, of tuber- 
culin, and then only after other measures have failed; 
hydro therapeutic measures suited to the condition and 
comfort of the patient ; ample diet, but not necessarily 
"forced feeding"; and the judicious use of medicinal 
antipyretics. 

Cough. — The treatment of the cough depends on 
whether it is dry or moist, and whether expectoration 
is easy or difficult. If the cough is dry and hacking, 
much of it may be prevented by the will-power of the 
patient. It should not be forgotten that many dry, 
irritating coughs are due to a lingual tonsil or throat 
irritation. Soothing, alkaline gargles, non-irritating 
inhalations of simple steam or steam medicated with 
some non-irritant drug, as a small amount of pine oil, 
will give relief. Many coughs of this kind are relieved 
by swabbing the lingual tonsil with boroglycerid. 
These dry, irritating coughs should be relieved with- 
out giving medicine by the stomach. 

If there is considerable bronchitis with insufficient 
expectoration, or the cough is frequent without expec- 
toration, the following cough mixture is soothing: 

Gm. or C.c. 

B Codeinae sulphatis |20 gr. iv 

Ammonii chloridi 5| 3 iss 

Syrupi acidi citrici 25| AS i 

Aquae q. s. ad 100J AS iv 

M. Sig. : A teaspoonful, in plenty of water, every two, three 
or four hours, as needed. 



COUGH IN TUBERCULOSIS 207 

Codein is the best sedative preparation of the 
opium series to meet the indication. The action of all 
other expectorants is inferior to that of ammonium 
chlorid, and ammonium chlorid as prescribed above is 
not disagreeable. The dose may be taken in Vichy or 
other sparkling water if desired. None of the multi- 
ple sweet, sickish, syrupy preparations offered by pro- 
prietary firms should be used in the bronchitis and 
catarrh of tuberculosis, or in any other kind of bron- 
chitis. It is not necessary to cause nausea or vomit- 
ing because a patient has a cough. The success of 
some of these syrups or malt preparations in dry 
cough is due to the fact that they soothe the throat 
and lingual tonsil. Such irritation can be allayed 
without the patient swallowing a mixture. 

If the cough is loose, and if the expectoration is pro- 
fuse, the stimulating effect of ammonium chlorid and 
the sedative effect of codein are not needed, and terpin 
hydrate becomes the best drug to use as an expectorant. 
To meet this indication of profuse bronchorrhea it will 
not ordinarily be necessary to combine it with codein. 
It should never be given in solutions, as not enough of 
it to be of advantage can be dissolved in any solution. 
It may be given in tablet, powder or capsule, and the 
usual dose is 30 eg. (5 grains), given with plenty of 
water four or five times in twenty-four hours. 

If there are cavities in the lungs, the patient should 
occasionally, by lying over the edge of the bed, allow 
gravity to aid him in expectorating the fluid and pus. 
Elevation of the foot of the bed is often of advantage. 
Sometimes inhalants containing creosote, oil of pine 
and benzoin are valuable. When there are large 
cavities which continue to fill up and cause septic 
fever, with the debility and loss of appetite that go 
with it, or when there is danger of serious hemorrhage, 
it may be wise to inject air or nitrogen into the pleural 
cavity and compress the diseased lung. Such treat- 
ment should be given only in hospitals or sanatoriums, 
and then by an expert, as very unpleasant symptoms 
may occur; the heart may be unpleasantly pressed 
upon and the outcome serious. On the other hand, the 
treatment is sometimes very satisfactory. 



208 TUBERCULOSIS 

Pain. — Pain in the chest is most frequently due to 
localized pleurisies, but it may be a neuralgia, or 
referred pain caused by disturbances of the more 
deeply seated nerves. Nothing is of more advantage 
in easing such pain than temporary strapping of the 
part of the chest affected. This is especially true of 
pain in the lower part of the thorax. - Sometimes a 
hot-water bag will ease the pain ; rarely a sedative may 
be indicated, but generally it is not needed. Mild 
counter-irritation by a liniment or ointment is some- 
times advisable over these regions of 'pain; blisters 
are rarely expedient, though the thermocautery may 
be used. Dry cupping may give relief. 

Hemoptysis. — Blood-tinged sputum or very slight 
pulmonary hemorrhages as evidenced by small clots 
or streaks of blood require no special treatment. Ex- 
pectoration of pure blood, or coughing up a little blood 
repeatedly requires' attention. Such a patient should 
rest, and should undergo no exertion. The diet should 
be light, and hot foods or hot drinks should not be 
taken for a day or two, until the hemorrhage ceases. 
For this kind of bleeding little other treatment is 
necessary. If the bleeding is more severe, the patient 
should immediately be placed in a semirecumbent posi- 
tion, with loosened clothing and should be assured that 
there is no danger, as there rarely is danger from 
hemorrhage during all the early stages of pulmonary 
tuberculosis. In the late stages, with cavities, a large 
blood-vessel may rupture and the hemorrhage be fatal. 
It is well to have the patient lie on the side which is 
bleeding. This tends to prevent the blood from flow- 
ing into the bronchi of the other lung. 

Besides reassuring the patient, it is often well, if 
there is a troublesome, irritating cough, to administer 
a hypodermic of morphin in just sufficient dose to quiet 
the irritability of the bronchial tubes and larynx so 
that the cough will be only sufficient for expectoration. 
(It is unnecessary to give a large dose which later will 
cause prostration; hence from 1/10 to 1/8 of a grain 
will be sufficient.) 

The more rest the bleeding part has, the quicker will 
the blood coagulate in the bleeding vessels, but as 
above stated, mere capillary oozing should not be taken 



HEMORRHAGE IN TUBERCULOSIS 209 

seriously. With a real hemorrhage from the lungs, 
the rest must be absolute ; the patient should not even 
speak, at least not above a whisper. For some hours 
he should receive no food or drink. It is exceedingly 
doubtful if an ice-bag over the region of the bleeding 
is at all efficacious. The long-used remedy of eating 
salt may reflexly, by irritation, increase the vasomotor 
tension and thus may occasionally stop a hemorrhage, 
but most of the remedies used and said to be satisfac- 
tory in hemorrhage from the lungs are drugs that 
increase the blood-pressure more or less, which is 
undesirable. As the blood-pressure is lowered, the 
hemorrhage will generally cease, usually without med- 
ication, so that whatever has been given has been 
supposed to be the cause of such cessation. If the 
patient becomes faint, blood-pressure is lowered, coag- 
ulation in the open vessel or vessels takes place, and 
the unpleasant symptom is cured' by Nature's meth- 
ods ; therefore we should aid the natural cure of the 
condition by giving the patient nitroglycerin to lower 
the blood-pressure. Amyl nitrite is very frequently 
advised, but its action is so sudden, and for a few 
minutes so intensely disagreeable, that it is hardly 
advisable to use this powerful drug. Nitroglycerin on 
the tongue or hypodermatically will act as efficiently 
and almost as rapidly without causing the faintness 
and throbbing head that amyl nitrite will cause. It is 
a mistake to give ergot, caffein, suprarenal prepara- 
tions, or digitalis, as these tend to increase the heart 
activity and raise the blood-pressure. 

If there is a tendency to repeated, more or less 
serious hemorrhages, the daily administration of cal- 
cium in some form, either as lime-water or calcium 
lactate, and the feeding of gelatin are indicated. Also, 
if there seems to be a general tendency to the oozing 
of blood and to hemorrhage, injections of aseptic 
horse-serum is advisable; one or two subcutaneous 
injections will generally be sufficient. Inhalations of 
steam impregnated with some astringent such as tannic 
acid may be of value, if there is oozing of blood from 
•the larger bronchial tubes, but such inhalations are of 
no value in bleeding from deeper portions of the 
lungs, as the astringent could not reach the region of 
trouble. 



210 TUBERCULOSIS 

The patient should generally remain in bed for a 
week after a real hemorrhage. If the heart is impaired 
and some dilatation exists, if the expectorated blood is 
venous, and there are other signs of passive congestion 
of the lungs and of cardiac weakness, digitalis may be 
the best treatment for the condition ; but for ordinary 
hemorrhages in pulmonary tuberculosis it is "better, as 
above stated, to administer nitroglycerin in sufficient 
amount to distinctly lower the blood-pressure tempo- 
rarily. 

It has been repeatedly noted that constipation 
increases the tendency to hemorrhage in pulmonary 
tuberculosis, and that the higher blood-pressure caused 
by constipation is readily lowered by the administra- 
tion of even simple laxatives. Consequently in pul- 
monary tuberculosis the patient should not be allowed 
to become very constipated. 

If the hemoptysis occurs late in the disease and is 
dangerous in amount, the patient may quickly suc- 
cumb, whatever the treatment adopted. A most 
efficient treatment of this serious condition is to place 
elastic bandages high up on the legs, or even on all the 
extremities, to shut off their blood from the general 
circulation. It would be inadvisable, even if the hem- 
orrhage was severe, to transfuse immediately, as any- 
thing that raises the blood-pressure will be likely to 
cause a return of the hemorrhage from the open ves- 
sel. Later, after the hemorrhage has ceased and suf- 
ficient time for thorough coagulation has passed, the 
bandages of the extremities, one at a time, may be 
released and the blood allowed to return to the general 
circulation. 

Continued bleeding from the lungs (especially when 
cavities exist and a serious hemorrhage has taken 
place, or seems likely to occur) is one of the most 
important indications for the use of lung compression. 
Other indications, as previously suggested, are the 
presence of pus in a cavity in the lungs, and bronchi- 
ectasis. It is also wise, perhaps, to compress a lung 
when, in spite of some weeks of proper treatment, the 
disease continues to spread in it, the other lung being 
normal. 






PNEUMOTHORAX 211 

The gases that may be injected into the pleural 
cavity are nitrogen, oxygen and nitrogen, oxygen and 
air, or air and nitrogen. If only temporary compres- 
sion is desirable, air, or a gas rich in oxygen seems 
indicated, as its absorption is more rapid. If a pro- 
longed compression is desired, nitrogen should be used, 
as it is less readily absorbed, and therefore the com- 
pression is longer continued. A mixture of air and 
nitrogen is perhaps a good combination when a brief 
compression is desired, and being more rapidly 
absorbed than nitrogen, will allow a decision as to the 
ability of the patient to stand this compression before 
using the longer compression by nitrogen. It has also 
been urged that air compression is safer than by nitro- 
gen from the fact that if gas bubbles enter the circula- 
tion, the air bubble is more quickly absorbed than the 
nitrogen bubble. Good technic with proper instru- 
ments, however, should preclude such an accident. 

If compression is once done and its continuance is 
desired, more gas should be injected before all of that 
previously injected is absorbed, as after an injection 
has once been made, and the pleural surfaces have 
come together, they become more or less adherent and 
it is difficult to inject the gas again into this pleural 
cavity. 

Night-Sweats. — This debilitating symptom is very 
characteristic of tuberculosis, and may occur even 
without much afternoon or evening fever; generally, 
however, it follows such increase of temperature. 
Therefore, the rest and fresh-air treatment that pre- 
vents a rise in temperature will also ameliorate or 
prevent the night-sweats. If, however, typical cold 
night-sweats occur, nothing in the way of medication 
more successfully prevents them than atropin, 1/200 to 
1/100 of a grain, given, dry on the tongue, at bedtime. 
The hydrotherapeutic measures already advised, that 
is, the warm water, and later cold water morning 
spongings are of value as preventives. If the patient 
is at rest and is getting no exercise, good massage 
followed by an alcohol rub is an excellent method of 
stimulating a more healthy circulation in the skin and 
muscles, and of diminishing the tendency to profuse 
perspiration. The avoidance of constipation, a healthy 



212 TUBERCULOSIS 

circulation and good activity of the kidneys, all pre- 
vent night-sweats and the accumulation of toxins in 
the blood. If there is much circulatory weakness, 
several doses of strychnin sulphate a day, or digitalis, 
may also prevent night-sweats. 

Diarrhea. — Simple diarrhea occurring in tuberculosis 
patients generally means either that the patient 
gets chilled, or that the diet is incorrect. Correc- 
tion of these conditions will soon stop such diarrhea. 
Tuberculous diarrhea, i. e., a diarrhea due to tuber- 
culous disease of the intestine is a serious complication 
not only of pulmonary tuberculosis, but also of any 
other form. It often occurs in the last stage of the dis- 
ease. Rest in bed and a carefully selected diet is 
the treatment. Whether the diet consists of milk 
alone, or of a little meat and eggs with milk, should 
depend on the patient. Generally, vegetables and fruit 
should be temporarily withheld, and the cereal foods 
diminished in amount. 

Bismuth subcarbonate may stop the diarrhea, but 
bismuth should not be long continued. Lime-water 
may be of benefit. If the kidneys are normal and 
there is no albuminuria, phenyl salicylate (salol) is 
good treatment. At times, one of the creosote com- 
binations is valuable. The administration of opium in 
some form may be necessary before diarrhea can be 
checked, and in the last stages of tuberculosis diarrhea 
may not be prevented. Colon washing with warm 
physiologic saline solutions is sometimes markedly 
sedative and of value. The bowels should always be 
kept especially warm, and the patient with diarrhea 
should not be subjected to intense cold. 

Dyspnea. — If the patient is in the last stages of 
pulmonary tuberculosis and must soon die, there is no 
excuse for not preventing the air-hunger, and morphin 
administered in properly selected, small doses will 
often relieve the dyspnea. 

The Pneumonic Type of Pulmonary Tuberculosis. — 
Such a condition is likely to occur as a part of acute 
miliary tuberculosis, but it may develop in a lung as an 
acute exacerbation of a chronic tuberculosis. The 
disturbance may be ushered in with a chill, high, irreg- 
ular temperature, frequent, short cough, considerable 






LARYNGEAL TUBERCULOSIS 213 

dyspnea, at first without physical signs of gross con- 
solidation, but later showing in a part of a lobe, or 
even the whole lobe, the usual pneumonic signs, even 
with rusty sputum. The rusty expectoration soon 
disappears, however, and yellowish, greenish sputum, 
perhaps blood-streaked and loaded with tubercle bacilli, 
occurs. The prognosis is very serious, but the acute 
exacerbation may cease. The treatment is not dissimi- 
lar from that of an ordinary pneumonia. 

Laryngeal Tuberculosis. — The prognosis of this con- 
dition has, up to recent years, been considered very 
bad indeed, but with more skilful treatment by throat 
specialists, with the added rest-cure and with tuber- 
culin treatment, many such cases are aborted and the 
lives of the patients saved. The instances of tuber- 
culosis of the larynx are rare in which, preceding or 
subsequent to the beginning of the laryngeal disease, 
some portion of the lungs will not be found affected. 

The exact local treatment of a tuberculous larynx 
depends, of course, on the location of the ulcer or 
ulcers. If they are so situated that swallowing is very 
painful, anesthetizing sedatives must be used. Various 
preparations of silver, lactic acid and menthol are used 
by different clinicians to aid in healing the ulcers, but 
the tuberculin treatment, properly used, is probably 
generally advisable. 

Tuberculous Peritonitis. — This condition uncompli- 
cated with tuberculosis elsewhere must, of course, be 
differentiated from many abdominal conditions. If 
there is fluid, other causes of ascites, as inflammation 
of the liver, serious cardiac insufficiency and ovarian 
cysts must be excluded. Tuberculous peritonitis may 
appear in several forms: the miliary form which 
causes ascites, the fibrocaseous, the fibro-adhesive and 
that which causes tumor masses. The range of tem- 
perature (although in chronic tuberculous peritonitis 
there may be no increase of temperature, and it may 
even be subnormal), the localized tumor masses and 
fluid confined to one portion of the abdominal cavity 
by adhesions, will aid in the diagnosis. In tuberculous 
peritonitis there may be more fluid on the left side of 
the abdomen than on the right, as the diseased mesen- 
tery retracts and draws the bowel to the right. As 



214 TUBERCULOSIS 

frequently tuberculosis is not present in other organs, 
the diagnosis is often difficult, and a tuberculin test is 
indicated. The fluid in the abdomen in tuberculous 
peritonitis does not contain pus, unless there is a mixed 
infection, as the tubercle bacillus does not produce pus. 
The drawn serum very frequently does not show 
tubercle bacilli, but a guinea-pig inoculated with the 
serum will, in due time, develop tuberculosis, if that 
is the infection from which the patient is suffering. 
If the exudate found on laparotomy or withdrawn for 
examination is bloody, it shows the disease is active. 
Tuberculous peritonitis may originate from infected 
mesenteric glands. Much false membrane is formed, 
which causes many adhesions of the intestines. 

A patient may apparently be very well and still 
suffer from tuberculous peritonitis, and the prognosis 
is rather favorable if such a patient is operated on. It 
is not advisable to operate for tuberculous peritonitis 
if tuberculous infiltration is already in the lungs. At 
times, withdrawal of fluid from the abdomen by aspira- 
tion, tonic treatment, rest and the exposure of the 
abdomen to the rays of the sun will cause a cure. 
Many sanatoriums are installing the necessary equip- 
ment for giving heliotherapy, or sun baths. The direct 
rays of the sun are thrown on the chest or abdomen. 
The electrochemical action of the roentgen ray has 
also been tried, but its value has not been well proved. 

If the ascites tends to recur, or remains, laparotomy 
should be done, and sunlight let into the abdomen. 
Laparotomy may cure tuberculous peritonitis when 
there are simply tuberculous masses or tumors, but no 
fluid in the abdomen. It has been thought that small 
doses of mercury administered for a long period, 
especially in the form of corrosive sublimate, was of 
advantage in tuberculous peritonitis. 

The results of operation may be summed up about 
as follows: There is slight danger from the operation 
itself. Temporary improvement may almost always 
be expected. Fatal cases usually terminate in a few 
months after the operation; while not far from one- 
third of all cases seem to recover in about one to two 
years after the operation. Antiseptic injections or 
continuous drainage after operation are not indicated 
and are useless. 



GLAND TUBERCULOSIS 215 

Tuberculosis of the Genito -Urinary Tract. — Tuber- 
culosis of the bladder and prostate is rarely primary, 
and often has gonorrhea as an antecedent. Tuber- 
culosis of the testicle is by no means infrequent. 
Removal of the testicle is of course advisable, and 
operative interference in the bladder and prostate may 
be indicated. A tuberculous kidney should be removed 
as soon as it is diagnosed provided the other kidney is 
normal. The general treatment is the same as in all 
tuberculosis. 

Tuberculosis of the Cervical Glands. — Although this 
subject has already been quite largely discussed, it 
should be urged that while surgical removal is neces- 
sary and very frequently indicated, every gland that 
is needlessly removed weakens by just so much the 
ability of the system to protect itself against all infec- 
tions. Roentgen-ray treatment, while lauded by some 
men, seems unsatisfactory to many clinicians. While 
infected or broken-down glands are being removed, the 
dissection should be very carefully done, lest the sur- 
rounding parts be infected with liberated germs, or if 
not locally infected, lest the bacilli be absorbed into the 
lymph circulation and cause general infection. 

While a gland should not be removed merely 
because it is enlarged, at the same time it is a serious 
mistake to allow enlarged glands to cause such inflam- 
mation of the surrounding tissues as to render it neces- 
sary to remove parts of muscles, to say nothing of 
the danger of such chronic inflammation necessitating, 
during operation, injury to important blood vessels 
and nerves. Glands should be removed before they 
cause injury to the patient or the surrounding tissues. 
Infected tonsils and infected teeth should be removed 
before the lymphatic glands or other parts of the body 
become infected. 

The tuberculin treatment of tuberculosis of the 
glands, especially in children, is much in vogue, and 
if the tuberculin is used in carefully graded doses 
the results seem to be satisfactory. Caseated glands 
should be eradicated or curetted, however, as the 
tuberculin treatment will not cause resorption. Also, 
the exact value of the tuberculin treatment for tuber- 
culous glands cannot be determined, as fresh air, good 



216 TUBERCULOSIS 

food, iron tonics, and medical supervision are active 
aids in the cure of this condition. Too large doses of 
tuberculin may overstimulate the diseased glands and 
cause general infection. Also, one does not know how 
many concealed diseased bronchial glands will be stim- 
ulated by the tuberculin injections; hence a very care- 
ful study of focal reaction should be made through- 
out the treatment. Bier's hyperemic treatment is 
probably inexcusable. 

Bone and Joint Tuberculosis. — In tuberculosis of 
these parts of the body, according to Fiske, there may 
be a slight leukocytosis of not far from 12,000, while 
in osteomyelitis the leukocytosis is generally not far 
from 16,000. Children who have bone tuberculosis 
frequently do well at sanatoriums or in hospitals espe- 
cially arranged for their out-door or veranda treat- 
ment. They do especially well at the* seashore, and 
direct sunshine makes a valuable addition to the treat- 
ment of this kind of tuberculosis. Tuberculosis of the 
glands and bone and joint tuberculosis do especially 
well under treatment by sun baths, both general and 
local, in combination with the invigorating effects of 
cold at moderately high altitudes. Rollier of Leysin 
and other practitioners at sanatoria in the Alps and at a 
few places in the United States have secured particu- 
larly good results by this form of treatment. Such 
treatment can be given at home by the institution of 
simple arrangements at first in the patient's room, later 
on a veranda and finally when the surgical condition 
will permit, by free movement in the open air. 

Tuberculous Meningitis. — Meyers (Amer. Jour. Dis. 
Child., May, 1915) classified the etiologic factors, 
symptoms and signs of 105 patients with tuberculous 
meningitis. Meyers found that 38 per cent, of these 
children had had no previous diseases; in the remain- 
ing 62 per cent, measles had occurred more fre- 
quently than any other disease. The average duration 
of the disease from the time of the beginning of symp- 
toms was seventeen days. Meyers thinks the disease 
is not so rapidly fatal as it once was on account of 
lumbar puncture being now more frequently done, thus 
preventing early deaths from cerebral pressure. 



TUBERCULOUS MENINGITIS 217 

Lumbar punctures were done from once to seven 
times to a single patient. He finds that lumbar punc- 
ture prevents convulsions, which become rare in the 
clinical history of the disease thus treated. Meyers 
believes that the advantage of lumbar puncture is not 
only in relieving pressure, but also in eliminating a 
certain amount of toxin. He has not found unpleasant 
symptoms to occur from the withdrawal of even a con- 
siderable amount of spinal fluid, even though it was 
not under high pressure. 

The rule of Meyers is to allow the spinal fluid to 
drain until it runs at the rate of from 10 to 12 drops 
per minute, and to draw off from 20 to 30 c.c. of fluid, 
depending on the pressure. Eighty per cent, of the 
cases showed increased pressure but varying, of course, 
in degree. If the child lived, lumbar puncture was 
done once every forty-eight hours. If the fluid removed 
at the first puncture did not show the organism caus- 
ing the meningitis, the later punctures usually did, and 
tubercle bacilli were found in 21.5 per cent, of these 
105 cases of tuberculous meningitis. 

When there was no increase of pressure in the 
cerebrospinal canal, there were almost no disturbances 
of the reflexes, and there seemed to be no relation 
between the amount of pressure and the presence of 
convulsions, bulging fontanel or retraction of the head. 
The fluid of this disease was never found really tur- 
bid, and was generally absolutely clear. The cell count 
of the fluid varied from 24 to 960 per cubic millimeter, 
with an average of 198. This cerebrospinal fluid cell 
count seems to vary with the leukocyte count of the 
blood : the greater the leukocyte count, the greater the 
number of cells in the spinal fluid. The prevailing type 
of cell in the spinal fluid was the small mononuclear, 
ranging from 90 to 100 per cent, in 67 per cent, of the 
cases, and from 80 to 90 per cent, in 20 per cent, of 
the cases. A fibrin clot was found in 70 per cent, of the 
cases, and a positive globulin test in about 50 per cent. 
The globulin content seems to vary directly with the 
cell count. The first part of the spinal fluid with- 
drawn at each puncture has a different cellular con- 
tent from the last part that is withdrawn, the first 
part giving the greater number of cells. 



218 TUBERCULOSIS 

One fourth of the cases showed a leukocyte count of 
the blood between 10,000 and 15,000; the lowest count 
was 8,500, and the highest 48,000. Absence of eosino- 
phils, as in some other diseases, is considered an 
unfavorable symptom. 

In those tested for the von Pirquet reaction, 63 per 
cent, were positive. 

Twenty-five per cent, of the cases gave a history of 
definite exposure to tuberculosis. Thirty per cent, of 
the cases showed lung involvement, and had more or 
less cough. In 71 per cent, the eye reflexes were 
abnormal, but in 29 per cent, the pupils were equal, and 
reacted normally to light. Thirty per cent, showed nor- 
mal patellar reflexes, and in 21 per cent, the reflexes 
were absent. There was a positive Babinski in 21 per 
cent. Fifty per cent, of the cases gave the Oppenheim 
sign. Ankle clonus was rarely present. Kernig's sign 
was present in 27 per cent, of the cases. Forty-three 
per cent, showed some signs of paralysis, with stra- 
bismus as the most frequent form. Seventy per cent, 
showed some rigidity of the neck, and, late in the dis- 
ease, there was definite stiffening of the limbs. 

While 39 per cent, of the patients had a history of 
convulsions before entering the hospital, as stated 
above, spinal puncture seemed to relieve or prevent 
convulsions. The subjective symptoms were drowsi- 
ness, indifference, and sometimes irritability. Eighty- 
five per cent, had vomiting as an initial symptom. This 
vomiting had no relation to the food taken, and in no 
case was there projectile vomiting as is so frequently 
seen in meningococcic meningitis. Pain was a frequent 
symptom. 

In 18 per cent, of the cases the urine showed acetone, 
and sometimes slight traces of albumin. 

Before death, pulse, temperature and respiration in 
about half of the cases became higher. Early in the 
disease the pulse was slow and irregular; later in the 
disease it became soft and rapid. In 64 per cent, of 
the cases there was a remission, with a drop of pulse 
and temperature ; but this was apparently not a sign 
of improvement. Also, a patient, who may have been 
comatose, may brighten up and answer questions from 



MILIARY TUBERCULOSIS 219 

twenty-four to thirty-six hours before death. Forty- 
two per cent, of the cases showed terminal bronchial 
pneumonia. 

In no case in this series was there recovery. The 
treatment tried was sodium benzoate in large doses, 
and inunctions of mercury. Hexamethylenamin was 
used in large doses, but even with these large doses 
there was never a trace of formaldehyd found in the 
spinal fluid. This seems again to disprove the value of 
this drug in cerebrospinal inflammations. 

Enough cases are now on record to show that recov- 
ery from tuberculous meningitis is possible, so that the 
prognosis is not absolutely hopeless, although very 
dire. If the child is suffering pain, codein or some 
form of opium should be administered in doses found 
sufficient for the individual, but not large enough or 
so frequently repeated as to produce coma; that is, if 
coma occurs it should be known that it is caused by 
the disease and not by the drug. The little patient, 
however, should not be compelled to suffer severe pain. 
Even if food is refused, the child will generally drink 
milk. 

Acute Miliary Tuberculosis. — This occurs in several 
forms; one in which all the organs of the body are 
attacked, others in which only certain organs are dis- 
eased. In another form the tubercles may be larger 
and show degeneration. The disease is always serious, 
generally fatal, and clinically occurs in the meningeal 
form just described or as a general acute bronchopneu- 
monia of both lungs, or as the typhoid type. In the 
lung form the sputum is loaded with tubercle bacilli 
and the diagnosis is readily made. In the typhoid form 
there may be no cough, and no real lung signs, 
although lesions may be found in the lungs on 
necropsy. It may be difficult at first to distinguish this 
form from typhoid fever, but the temperature is likely 
to be very high in the evening with considerable of. a 
drop in the morning, and there are profuse sweatings. 
Such morning remissions occur early in the disease, 
thus differing from typhoid fever. The pain and ten- 
derness in the abdomen, and the point and cerebral 
symptoms, will soon make the diagnosis positive. Diar- 
rhea generally does not occur with acute miliary tuber- 



220 TUBERCULOSIS 

culosis ; in fact, the patient is generally constipated — 
another symptom different from most cases of typhoid 
fever. 

The treatment is similar to that of any acute infec- 
tion with the exception that great care should be exer- 
cised to sterilize every excretion from the body. 

Tuberculous Arthritis. — Cases occur of pain and 
swelling of the joints due either to the circulation of 
tuberculous toxins in the blood or to the presence of a 
small number of tubercle bacilli in the affected joints. 
It is probable that a considerable number of cases of 
ordinary rheumatism are due to tuberculosis. An 
almost positive sign of such cases is the occurrence of 
focal reactions (pain and swelling) in the joints after 
injection of old tuberculin subcutaneously. 

PROGNOSIS 

In the first place, as to the probability' of cure of 
tuberculosis, it should be remembered that statistics of 
necropsies show that from 30 to 35 per cent, or more 
of patients who have died from causes other than 
tuberculosis show evidence of that disease, either 
healed or latent. In general, the prognosis of pul- 
monary tuberculosis is modified by the family history, 
by the causes which have allowed the tuberculosis 
to develop, by the whole general condition of the 
patient, and by the amount of lung tissue involved. 
A tuberculous process that begins in the lower part of 
the lung, following a pneumonia, gives a bad prog- 
nosis. A generally debilitated and anemic condition 
will necessarily slow or preclude a cure. An associated 
laryngeal or intestinal complication makes the prog- 
nosis very serious. 

When a patient is first seen, the prognosis should be 
guarded, as it is only after weeks or months that the 
decision can be made as to how much this patient may 
improve, as even a person who looks otherwise well, 
except for the fact that tuberculosis is discovered, may 
develop an acute form of the disease. The physician 
should individualize the patient, not only as to his sur- 
roundings and his occupation, but also as to his men- 
tality. His disposition should be studied. It is a 



PROGNOSIS IN TUBERCULOSIS 221 

mistake to send to a sanatorium a patient who will be 
restless under sanatorium restrictions, or who will be 
so seriously homesick as to lose his appetite, or who 
will not at all obey instructions. Therefore, the men- 
tality, the individuality and the willingness to cooper- 
ate of the patient is of great importance in the prog- 
nosis. 

According to Combe (Le Nourrisson, 1916, 4, 202), 
the opinions of pediatricians differ as to the prognosis 
of tuberculosis in infants. While most declare that, 
when diagnosed clinically it is absolutely fatal, others 
affirm that they have seen infants survive tuberculous 
disease. Combe is of the opinion that the prognosis of 
tuberculosis in infants is very grave, but not inevit- 
ably fatal. He thinks the outcome depends on a 
number of factors. The age of the child at the time 
of infection is the first point to consider. The younger 
the child is at this time, the less capable he is of 
defending himself and the greater is the tendency of 
the tuberculosis to become generalized. The virulence 
of infection and the opportunity for reinfection are 
important factors. Contact with open tuberculosis 
offers this opportunity for reinfection. It is usually 
admitted that infection from the mother is more dan- 
gerous than that from other members of the family, 
and that the danger is the result of reinfection. 

The clinical form of the disease is most important 
in prognosis. If when the diagnosis is made the tuber- 
culosis is still localized in the glands, a less serious 
prognosis can be given. If the glandular barrier is 
broken down and there is mediastinal and hilus infil- 
tration, the case must be regarded as very serious, 
although the author affirms that he has seen symptoms 
recede and apparent recovery result from tuberculin 
therapy. If signs of generalized tuberculosis are 
present and the roentgen ray confirms the diagnosis 
of miliary tuberculosis or of acute caseous pneumonia, 
the case must be regarded as desperate. Chronic 
surgical tuberculosis is the only form which offers a 
good prognosis. This is caused by a spontaneous auto- 
tuberculin therapy from the slow progressive penetra- 
tion of tuberculin into the general circulation. 



222 TUBERCULOSIS 

It is a question whether asthma, which was long sup- 
posed to protect against tuberculosis, really does so. 
Certainly an asthmatic patient may have tuberculosis. 
It seems to be a fact that persons who suffer from 
heart-disease, especially if there is a sufficient loss of 
compensation to cause more or less dyspnea and pul- 
monary passive congestion, do not have tuberculosis so 
readily. This subaeration may interfere with the 
growth of tubercle bacilli. 

Tuberculosis of the cervical lymph-nodes may be 
due to an auto-infection. In other words, bacilli may 
be contained in the patient's own sputum, infect the 
tonsils and be from there carried to the cervical glands. 

A more or less continuously rapid pulse gives a bad 
prognosis. A temperature that is not greatly lowered 
by rest gives a bad prognosis. Of course, the case is 
serious as long as there is a morning fever. A patient 
whose temperature is normal or subnormal in the 
morning, even if there is considerable rise in the after- 
noon and evening, may not only improve, but may 
recover. Any sexual excess, and even any sexual act 
during tuberculosis will aggravate the condition. A 
slight gain in weight, while desired and looked for, 
and generally an indication that the patient is improv- 
ing, is not necessarily a positive indication that the 
prognosis is absolutely good, as many instances occur 
in which the patient gains weight for a time, under 
proper treatment, but the disease progresses. There- 
fore, a slight but steady gain in weight should be con- 
sidered satisfactory, but should not cause too favorable 
an opinion of the outcome to be given. 

It is considered a good prognosis when the lympho- 
cytes in the blood are increased in number, showing 
that the nutrition is improving. It has also been con- 
sidered that a normal number of eosinophils gives a 
good prognosis, while an absence of eosinophils gives a 
bad prognosis. Whatever the condition, however, it 
should constantly be borne in mind that pulmonary 
tuberculosis is curable in the first and second stages, 
and a cure may even take place in the third stage, or 
when there are cavities. 

Pregnancy in a tuberculous patient makes the prog- 
nosis bad, and should call for a consultation to decide 
as to whether or not abortion should be produced. 



ARRESTED TUBERCULOSIS 223 

ARRESTED TUBERCULOSIS 

A patient who has even a temporary return to health 
must generally go to work, and the question of vital 
importance is, What shall the work be? There is 
no light outdoor work suitable for such recovered 
patients; hence, unless the occupation is one that is a 
menace to his health, a patient should return to his 
previous work. The education received during his 
cure should have taught him how to live to keep his 
health. The next important rule for him to follow is 
to return to his physician for observation and advice 
at frequent intervals. 



DISEASES OF THE RESPIRATORY 
TRACT 



COMMON COLDS 

Colds far surpass in frequency any other disease 
condition. There is no immunity acquired by surviving 
a coryza, a pharyngitis or a bronchitis; in fact, or- 
dinarily, the person is at least temporarily more sus- 
ceptible to taking or developing a fresh cold. This 
may not be quite true of an influenza or grip cold, 
because many persons have a real or pseudogrip attack 
early in the fall or winter and are then more or less 
immune from acute attacks during the rest of that 
season. Besides the immediate debility that an acute 
cold causes, the possibility of opening the way for the 
entrance of more serious disease should cause every 
cold to be considered seriously and treated energetically. 

Acute colds are always due to germs of some kind. 
A too dry atmosphere, which is the condition in so 
many houses today, may so irritate or congest the 
nostrils as to allow the least irritant to cause at first a 
simple inflammation of the mucous membrane, which 
congested area may later pick up and harbor, or cease 
to kill, germs. Outdoor air does not predispose to 
colds as much as indoor air, and persons whose occu- 
pation is indoors are more liable to have colds than 
those whose occupation is outdoors. Chilling, whether 
indoors or outdoors, certainly predisposes to colds. It 
is quite probable that chilling of the surface of the 
body congests the inner organs and possibly the mu- 
cous membranes of the air passages. If the mucous 
membrane of the nose is congested, it more readily 
becomes inflamed. 

Acute nas? 1 inflammation, often called a "cold in the 
head," is of i- ?quent occurrence in some regions, espe- 
cially near the seacoast, and occurs repeatedly in cer- 
tain persons who seem to have a susceptibility to in- 
flammation in the nose. Some persons cannot be 
exposed to a single draft on any part of the body 
without an acute coryza starting. It is supposable, 
however, that while most acute nasal inflammations 



BACTERIOLOGY OF COLDS 225 

are due to infectious germs, more or less chronically 
hypertrophied mucous membrane and more or less 
sluggish circulation in this membrane may allow simple 
noninfectious inflammations to occur when irritation of 
any kind is applied. Other persons who do not have this 
susceptibility may become chilled, may be subjected to 
violent cold, damp winds, and may even get wet and 
still never develop a nasal inflammation. Just as large 
tonsils more readily catch germs and become diseased, 
or more readily harbor germs and have recurrent 
inflammations, so hypertrophied mucous membrane of 
the nostrils becomes susceptible to reinfection or to 
reirritation. Frequent acute colds, more or less con- 
stant subacute inflammations, or chronic inflammation 
may result from such a condition. 

BACTERIOLOGY 

Tunnicliff (Jour. Infect. Dis., 1913, 13, p. 283) in 
the acute and chronic forms of rhinitis, isolated an 
anaerobic gram-negative bacillus, which she named the 
Bacillus rhinitis. Kruse, (Munchen. med. Wchnschr, 
1914, 61, p. 1547) working along the same lines, was 
able to demonstrate that when the secretions from the 
discharge in cases of acute rhinitis were taken and 
diluted even as much as twenty times, and then filtered, 
the filtrate inoculated into the noses of healthy people 
produced typical cases of acute rhinitis. As a result 
of this he concluded that the acute rhinitis was caused 
by an invisible and filterable virus, since the filtrate 
when cultured remained sterile. 
/ Foster, (Jour. A. M. A., April 15, 1916, p. 1180) 
repeated Kruse's experiments and obtained similar 
results. He, however, went further, and using Nogu- 
chi's method for growing the parasite of rabies and 
the organism of poliomyelitis, was able to obtain from 
the filtrate an organism which, when inoculated into 
the noses of seven soldiers, produced a typical condi- 
tion of acute rhinitis in all of them. 

PROPHYLAXIS 

The preventive measures consist of proper bathing 
to keep the skin in good condition; proper clothing, 
depending on the region, season and exposure ; proper 



226 PROPHYLAXIS OF COLDS 

heating and ventilation of living rooms, bedrooms and 
buildings in which persons are employed, and in the 
case of the child, proper heating and ventilation of 
the schoolrooms. Too severe exposure of young chil- 
dren and babies to dampness and winds is inexcusable 
and does not increase their resistance against catching 
cold, and often precipitates more serious conditions. 
Any person who has a tendency to nasal or pharyngeal 
colds should not suffer undue exposure at night. Too 
many windows being open may cause too much direct 
draft over the face. Fresh air sleeping should be gov- 
erned by common sense. Cold daily sponging of the 
child's face, neck and chest, followed by quick friction, 
is a splendid means of decreasing the likelihood of 
catching cold or becoming chilled. Older persons may 
take cold showers or cold plunges in the morning, if 
it is advisable in individual cases. 

Children especially should not be subjected to 
unnecessary infection by being taken into crowded 
cars, stores or into assemblages, where it is imprac- 
ticable to avoid close contact with coughing or sneezing 
persons who do not properly protect the surrounding 
atmosphere by using handkerchiefs. 

As so many times urged, a child or adult who has 
repeated colds should be examined and properly 
treated medically or surgically by a nose and throat 
specialist. The family should also be taught that the 
exchange of handkerchiefs and the use of the same 
towels when one member of the family has a cold or 
sore throat is inexcusable. Direct contagion by this 
method is probably very frequent. During all colds 
the nasal and throat secretions or excretions should be 
received into paper handkerchiefs, or pieces of cheese- 
cloth, and either immediately burned or deposited in 
a paper bag for burning later. If handkerchiefs are 
used, they should be washed separately and soon. 

A too dry indoor atmosphere can harm the mucous 
membranes of the upper air passages as it leaves the 
membranes unprotected, and the first irritant that 
attacks them may cause an inflammation. 



TREATMENT OF COLDS 227 

TREATMENT 

Acute coryza having begun, an attempt should be 
made to abort it. There are various methods of reliev- 
ing internal congestions, and the general principles are 
the same in all cases, wherever the localized inflamma- 
tion may be. These general methods are some means 
to reduce an increased temperature, some means of 
bringing the blood to the surface of the body and 
increasing perspiration, some means to produce free 
catharsis and thus to deplete the blood-vessels and 
lower the blood-pressure to relieve indirectly the ten- 
sion in the region of congestion, and some means to 
prevent the development of the second stage, or stage 
of secretion, if possible. Methods used to meet one 
of these indications will many times meet one or more 
of the others ; hence the treatment is often very simple. 

If the patient is first seen in the morning, or before 
the middle of the afternoon, the best treatment is a 
saline purge of some description, as exemplified by the 
Seidlitz powder or by the effervescing magnesium cit- 
rate or Rochelle salt, or castor oil if that is preferred. 
If the patient is seen first in the evening, a less quickly 
acting cathartic is advisable. A single dose of the 
aromatic fluidextract of cascara sagrada, U. S. P., may 
be given at bedtime. The dose may vary from 4 c.c. 
for a child of 3 to 5 years of age to from 4 to 16 c.c. 
for an adult. More active purgation may be 
secured with calomel, or with an aloin pill. The 
old-fashioned Dover's powder is still given by many 
physicians and often works well, but may cause con- 
siderable nausea. Also, opium, or morphin in any 
form tends to inhibit free action of the bowels, which 
is undesirable. One of the best treatments is one of 
the coaltar products, such as antipyrin, acetanilid or 
acetphenetidinum. Any one of these may be given in 
one fair-sized dose or in two medium-sized doses, or in 
several small doses. One gm. of antipyrin would be a 
full dose ; 0.50 gm., repeated in five or six hours, would 
be a medium dose ; 0.30 gm. of acetanilid would be a 
large dose, and 0.10 gm. might be repeated at three- 
hour intervals for three times. A satisfactory method 



228 USE OF RHINITIS TABLETS 

is a combination of acetanilid with sodium bicarbonate, 
and a prescription similar to the following is often 
very valuable : 

Gm. 

B Acetanilidi 01 25 or gr. v 

Sodii bicarbonatis 2} 50 gr. xl 

M. et fac chartulas 5. 

Sig. : One powder every two or three hours. 

A similar combination may be given in tablets, if 
preferred. It should be remembered that caflein has 
been shown not to protect the heart from depression 
causd by large doses of a coaltar product; therefore, 
there is no object in adding caffein to such a prescrip- 
tion. When these coaltar products are ordered, it is 
well to give coincidently hot lemonade. Perspiration 
is more readily caused by this means. 

Provided the patient is not soon to be subjected to 
exposure, a hot bath is another efficient means of 
relieving internal congestions, and can be used coinci- 
dently with the other treatment. Acidum acetylsali- 
cylicum (aspirin) is now more largely used than 
almost any other drug to abort colds. The laity, on 
account of the instructions which they have received of 
the dangers of acetanilid and similar drugs, now all 
buy and use this drug with too great freedom. 

Rhinitis tablets are sold everywhere to the laity, and 
are largely used by physicians. These are various 
combinations of morphin, atropin, strychnin and aconi- 
tin. The minute dose of aconitin probably gener- 
ally has no action. If one desires the activity of 
aconite, it is best to give it in a tangible form and dos- 
age, namely, the tincture of aconite, a drop perhaps 
every half hour or hour, until the pulse shows the 
activity of the drug. However, this treatment ordi- 
narily requires that the patient be seen within a certain 
number of hours by the physician, to ascertain whether 
or not the aconite should be stopped, unless the doses 
are limited in number. The old aconite treatment of 
colds has mostly given place to the newer treatments 
described above. The whole rhinitis tablet combina- 
tion probably represents principally the action of 
atropin with some help from the morphin, both of 
which will dry up the secretions of the nostrils and 
throat. The small amount of strychnin probably is 



SPRAYS FOR COLDS 229 

not very active. Sometimes minute doses of quinin 
enter into these combinations, but that probably is not 
active. In other words, a small dose of atropin sul- 
phate, given frequently, acts as well as one of these 
rhinitis combinations. 

There is no question about the drying up of secre- 
tions by morphin, if this drug is pushed. Rarely is 
such treatment needed. 

Quinin sulphate has been used for years as an abor- 
tive treatment of colds, and the laity, until more 
recently adopting acetylsalicylic acid, have always 
resorted to this drug. Small doses would probably 
not have any very decided action ; large doses are 
inadvisable at this stage of the cold because of the 
tendency to congest the middle ear. 

Spraying or snuffing solutions into the nostrils at 
this stage is inadvisable. The throat may be gargled 
with warm physiologic saline solution, which is 
roughly represented by *4 teaspoonful of salt to half a 
glass of warm water. If the patient has been known 
to be' exposed to some acute throat or nasal infection, 
more active antiseptic gargles and sprays may be used ; 
but an acute coryza will rarely be aborted by local 
treatment. 

If the inflammation is not aborted and the second 
stage develops, that of profuse mucus and some muco- 
purulent discharge, then cleansing of the nose and 
throat becomes urgently needed. At this stage all of 
the foregoing abortive measures should cease. A 
patient who has been more or less deprived of food, 
except a small amount of liquid nourishment for from 
twenty-four to thirty-six hours, may now resume his 
normal diet. 

The more or less purulent discharge from the nos- 
trils should not be allowed to remain blocking up the 
passages. Consequently, atomizing with warm saline 
and alkaline solutions should be more or less fre- 
quently done. Various compound solutions or tablets 
for solution are offered, but there probably is no advan- 
tage in these combinations over more simple ones. 
The simplest cleansing solution is one made from y 2 
teaspoonful of salt and y 2 teaspoonful of sodium bicar- 
bonate to a glass of warm water, or half these amounts 
for half a glass of water. To be properly soothing, the 



230 CLEANSING THE NASOPHARYNX 

solution should always be warmed. The same solu- 
tion may be used as a gargle. If a mild antiseptic is 
needed, saturated solutions of boric acid or borax are 
efficient. If stronger antiseptic solutions are required 
or advisable, hydrogen peroxide is valuable, as 1 part 
of the official aqua hydrogenii dioxidi to 4 or 5 parts 
of warm water for a gargle, or 1 part to 7 or 8 parts of 
warm water for a nasal spray. Nasal spraying and 
proper cleansing of the nose protects the adjacent 
sinuses from infection. 

Cleansing the nasopharynx by snuffing back a solu- 
tion from a teaspoon or a small vial, or snuffing back 
a spray, or gargling and then throwing the head for- 
ward and washing the nasopharynx, protects the 
eustachian tubes from infection. Two cautions should 
be suggested : first, that douching of the nasal passages 
should not be done with the nostril blocked, or with a 
high placed douche reservoir, as the pressure is likely 
to be sufficient to send fluid into the eustachian tubes 
or into the sinuses, and cause inflammation of such 
parts. Most of the patented douche apparatus are inad- 
visable. The second precaution is that it is not well to 
cleanse the mucous membrane of the nostrils too thor- 
oughly of mucus before the patient goes into the out- 
side air, especially if that air is dust-laden. The proper 
time to spray is when the patient is to remain in the 
house for a short time; or if he is sprayed and then 
must go out of doors, he may receive a non-irritant oil 
spray to furnish coating for the mucous membrane, 
this is to be used after the alkaline spray. Or small 
plugs of cotton may be placed in the nostrils. 

It may be well at this time to use a camphor-men- 
thol oil mixture either as drops or as a spray. The fol- 
lowing may be suggested : 

Gm. or C.c. 



$ Menthol 

Camphor 

Liq. petrolatum 50 



If the secretion from the nose is tenacious and hard 
to dislodge by blowing the nostrils, ammonium chlorid 
may be a drug of value. It has been used as a stimu- 
lant to the upper air passage mucous membrane as well 
as to the bronchial mucous membrane. It may be 
given in a simple preparation as : 



ACUTE PHARYNGITIS 231 



Gm. or C.c. 

I£ Ammonii chloridi 5 

Syrupi acidi citrici 25 

Aquae q. s. ad 100 



3 iss 
or flSi 
flSiv 



04 


aa 


gr. 


% 





or 


gr. 


XV 







gr. 


XXX 



M. Sig. : A teaspoonful, in water, every three hours. 

If the coryza tends to become subacute and pro- 
longed, tonic treatment is required; a small dose of 
quinin and a small dose of iron, with or without 
arsenic and strychnin, are advisable. The following 
tonic capsule may be used, and the doses may be modi- 
fied for a child : 

Gm. 

B Arseni trioxidi 

Strychninae sulphatis 

Ferri reducti 1 

Quininae sulphatis 2 

M. et fac capsulas siccas 20. 

Sig. : A capsule three times a day, after meals. 

Spraying with suprarenal solutions is often of 
advantage, but sometimes is followed by more conges- 
tion. Some nose and throat specialists use suprarenal 
preparations constantly. Such treatment certainly 
many times is efficient in temporarily relieving conges- 
tion and giving comfort. 

This discussion of the treatment of common colds 
would not be complete without reference to the vaccine 
treatment. While the exact value of such treatment 
has not been determined as an abortive treatment or as 
a treatment that shortens the course of the disease, the 
enthusiastic recommendation of such treatment by 
some writers should be recognized. The large majority 
find no value in vaccines either for prophylactic or 
curative purposes. When there is sinus infection, auto- 
genous vaccines would seem indicated. 

ACUTE PHARYNGITIS 

The abortive treatment of this inflammation is the 
same as that described for acute colds. 

With a simple pharyngitis, soothing alkaline gargles, 
as previously described, should be the treatment. A 

ivery simple, pleasant and efficient gargle is as fol- 
lows: 



Gm. 


or C.c. 




2 




3 ss 


2 


or 


3 iss 


200 




flBvii 



232 ETIOLOGY OF COUGH 



fy Acidi borici 

Potassii chloratis 

Aquae menthae' piperitae. . . 
M. Sig. : Use as a gargle, every three hours, diluted with 
equal part of warm water. 

COUGHS 

DEFINITION 

Coughing is an expiratory effort caused reflexly by 
some irritation. The muscles of the lower part of the 
chest are most engaged in the act of coughing; hence 
in severe, prolonged or frequent coughing muscle tire 
occurs in the lower part of the chest, both anteriorly 
and posteriorly. The abdominal muscles all take part 
in this expiratory effort, and the erector spinae mus- 
cles, the serratus, and the quadratus lumborum are 
all utilized in a strong expiratory cough. The mus- 
cle contractions compress in all directions the lower 
part of the chest, and the air in the bronchial tubes 
is forced upward, and, if there is no obstruction, is 
expelled through the glottis. If there is obstruction, 
or even partial obstruction, the upper portion of the 
lungs, especially the apices, become dilated, and tem- 
porarily, or in severe cases, permanently, emphysema- 
tous. 

causes 

Cough can be caused by irritation of any of the 
mucous membranes of the air tract, by irritations of 
the nerves in the lung tissue, by irritations of the 
pharynx, by reflex irritation of the vomiting center, 
and by any irritation that can reach, through the 
pneumogastric nerve, the center in the medulla. From 
any of these reflex causes efferent impulses are trans- 
mitted, and the result is a cough. Irritation in the 
nose and ear may cause cough. 

Pain and muscle tire from prolonged coughing, 
besides occurring in the lower part of the chest, occur 
in the sides, low down, perhaps in the region of the 
insertion of the diaphragm, and also in the back even 
down in the lumbar region. These strong contrac- 
tions of the abdominal muscles during coughing also 
aid in temporarily diminishing the capacity of the 



TYPES OF COUGH 233 

thorax by pushing upward the abdominal organs. At 
the same time there is a considerable force exerted 
downward, which may tend to cause uterine displace- 
ment, hemorrhoids and even involuntary urination. 

Before this forcible expiration or cough there is 
generally a deep, quick inspiration ; then the glottis is 
partially closed and the air is propelled upward for- 
cibly, causing friction which tends to expel anything 
on the walls of the mucous membrane of the bronchial 
tubes and trachea. Even in simple bronchitis, if 
there is much coughing, there will be found increased 
resonance in the apices of the lungs, as there is prob- 
ably always a temporary emphysema. 

Nasal irritations may produce cough as frequently 
as they cause asthma. Irritations of the nasopharynx 
and pharynx proper frequently cause coughing, which 
is very likely to be accompanied by retching and even 
vomiting. An elongated uvula may tickle the epiglottis 
and cause spasmodic, quick expiratory coughing. This 
cause, however, is rare compared with the frequency 
of cough caused by an enlarged lingual tonsil, whether 
the tonsil is hypertrophied, contains dilated blood- 
vessels, or is inflamed. Any disturbance of this gland 
or lymphoid tissue may cause a tickling in this region 
sufficient to produce a very irritating and disturbing 
dry cough, which comes on sometimes in paroxysms, 
until a certain amount of mucus is literally scraped off. 
The very intensity of the cough so irritates the part, 
like scratching a spot on the skin that itches, as to 
stop the tickling sensation for a time. Irritations of 
the larynx almost always cause cough. Hence no 
examination of a patient who coughs is complete with- 
out a throat and larynx observation. 

TYPES OF COUGH 

The dry bark of spasmodic croup is very character- 
istic. The noise is low pitched, and is a bark. If it 
is husky there is mucus or membrane present. 

The cough of bronchitis can be of all descriptions ; 
it may be dry, may be non-productive, and may be 
moist and productive. Pain in such cough (the same 
is true of grip) is referred under the sternum, and is 



234 TYPES OF COUGH 

due largely to the vibrations of the air on the inflamed 
mucous membrane of the trachea and perhaps larger 
bronchi. 

The cough of pneumonia is at first somewhat pain- 
ful, and the pain is referred to the side, near the 
nipple. This cough may be at first dry, but is soon 
productive and generally should not be discouraged. 

The cough of pleurisy is non-productive and unde- 
sired, and is never loud, as it is repressed. It causes 
pain referred to the side. There is nothing to expec- 
torate, and it should be discouraged and stopped. 

The cough in the first stages of tuberculosis is often 
dry and catchy; it is a hack. There is no great inten- 
sity .to this cough, and no necessity for it, and it 
should be discouraged. As soon as there is much local 
bronchial catarrh the cough should, as it is then pro- 
ductive, not be discouraged, except at meals, and in 
the presence of others; that is, such patients should 
be taught when to cough. In laryngeal tuberculosis 
the ulceration of the cords produces usually a peculiar 
croaking cough. 

The cough of asthma is a wheezing affair and 
accompanied by all sorts of rattlings; the same type 
occurs in a stuffy, asthmatic bronchitis. This cough is 
generally not harsh. 

Nervous cough usually consists of a single effort 
often repeated from time to time with monotonous 
regularity. 

The coughs of different individuals vary. Some 
always cough with great intensity, and others easily 
and lightly. Older persons seem to raise mucus and 
pus from the bronchial tubes with difficulty, and it 
takes a great many coughs to raise the sputum for 
expectoration. Young children cough easily, but gen- 
erally swallow their sputum. Very weak patients 
will hardly expectorate at all. In such cases the foot 
of the bed may be raised at night; also when they 
cough while in bed, they should turn onto the side or 
stomach in order to raise the sputum, or they should 
lean over in order to have gravity aid as much as 
possible the expulsion of the mucus, etc. The cough 
of pertussis occurs in showers or paroxysms, and at 
the height of the disease the glottis closes during inspir- 



ACUTE BRONCHITIS 235 

ation, and the air is sucked in through a more or less 
narrow slit, giving the characteristic "whoop." 

Persons coughing very hard, as typically in. whoop- 
ing cough, but also in emphysema and in the severe 
bronchitis of strong, sturdy men, will cause a great 
deal of cardiac disturbance by retarding the flow in 
the large vessels of the thorax, thus increasing the 
work of the heart, especially of the right side. Such 
coughing can force backward the blood in the large 
veins thus congesting all the organs, notably the eyes, 
face and head, and whooping-cough can cause a cere- 
bral hemorrhage or a hemorrhage into the eyes. These 
patients may not infrequently have nosebleed, and even 
vomit blood. 

ACUTE BRONCHITIS 

There is no question that, whether bronchitis occurs 
in an adult or in a child, the patient will recover more 
quickly if he remains in bed for one or more days. 

The prophylactic treatment is the same as for an 
acute coryza, and these treatments will more or less 
relieve the congestion in the bronchial tubes and pro- 
mote expectoration, if the disease is not aborted. The 
cough is at first non-productive, but as soon as mucus 
begins to be plentifully secreted the cough is pro- 
ductive, the tightness of the chest is relieved, and the 
patient feels better. One of the best promoters of a 
free mucus secretion is ipecac, and a few drops of the 
syrup of ipecac, given every hour, unless nausea is 
caused ; or from 0.03 to 0.05 gm. (about y 2 to 1 grain) 
of the powdered ipecac may be given every two hours. 
The ipecac should never be pushed to the point of 
causing uncomfortable nausea. The dose should, 
therefore, as suggested, be very small. 

In the second stage of bronchitis there is no expecto- 
rant that seems to work so well as ammonium chlorid, 
and the dose should be about 0.25 gm. (4 grains) every 
two hours. The bad taste of this drug may be well 
covered up by giving it in a sour mixture, as the syrup 
or citric acid and water. If the cough is excessive and 
more than the secretion calls for, there is possibly no 
better method for its control than to give small doses 
of codein sulphate. This may be combined with the 
ammonium chlorid in a sour mixture, as : 



Gm. 


or C.c. 







20 


gr. iv 


5 




3iss 


25 




flSi 


100 




flSiv 



236 TREATMENT OF BRONCHITIS 



fy Codeinae sulphatis 

Ammonii chloridi 

Syrupi acidi citrici 

Aquae <. . . .q. s. ad 

M. Sig. : A teaspoonful, in water, every two or three hours. 

This prescription is for an adult, but it may be 
readily modified according to the age of the child. If 
the codein is not desired, it may be omitted. If it is 
desired to give the ammonium chlorid less frequently, 
the .dose may be made larger. If a sweeter mixture 
is preferred, the syrup of tolu may be substituted for 
the syrup of citric acid; or both the syrup of citric 
acid and the water may be omitted and the syrup of 
wild cherry substituted. 

If the larynx is inflamed, the inhalation of simple 
steam, or ' of medicated vapors, may be of value, 
but a patient with laryngitis of any type should be 
under very careful observation by a physician. The 
steam for inhalation may be modified by adding to 
the boiling water oil of eucalyptus, 5 minims to the 
pint, or compound tincture of benzoin, 1 dram to the 
pint. 

If the expectoration becomes more profuse and 
seems not to stop readily, terpin hydrate is of value. 
The dose is 0.30 gm. (5 grains) about four times a 
day. This may be given in tablet or in powder; solu- 
tions are unsatisfactory as it is very insoluble. If 
deemed advisable it may be combined with codein in 
small doses. 

If the coughing persists longer than a week, the 
sputum should be examined to determine what germs 
are present. If it proves to be a simple bronchitis, 
but prolonged, sodium .iodid in small doses may be 
of value, especially if the patient is at all asthmatic, 
or should he be an elderly person. Fresh air, good 
food and iron are always of value in curing all kinds of 
bronchitis. If the patient is a child and the nutrition is 
poor, plenty of good food rich in fats should be sup- 
plied. A bronchitis that will not stop must be treated 
as a pre-tuberculous stage of tuberculosis, and the 
patient should receive climatic, or open air rest cure 
treatment. 






ASTHMA 237 

It should be emphasized that a patient with bron- 
chitis is not properly supervised unless the tempera- 
ture is taken, and this more or less frequently. A 
patient with a fever should remain at home, if he 
wishes to avoid complications that readily occur from 
an acute bronchitis or grip. The district nurse or the 
medical inspector should always take the temperature 
of a coughing child. If a child has any fever, it should 
be sent home and the family physician summoned. 

ASTHMA 

In the first place, the disease asthma should be disso- 
ciated from conditions which are termed asthmatic. A 
patient may be. asthmatic from various causes, but the 
term asthma should be limited to the disease or condi- 
tion itself, i. e., periodic attacks of bronchial spasm. 
More or less continued dyspnea, with or without 
whistling rales, and with or without acute attacks of 
asthma, may be caused by cardiac disease, cardiac 
asthma ; by renal insufficiency, renal asthma ; by pleth- 
ora, causing attacks of acute hyperemia of the lungs; 
by arteriosclerosis ; emphysema; diabetes; thyroid dis- 
turbances, and by the various anemias. Spasmodic 
asthma may be caused by bad heart attacks ; by acute 
toxemia from renal insufficiency; by exacerbations of 
gout, probably due to a toxemia from nitrogenous mal- 
metabolism; by acute indigestion, and by gastrointes- 
tinal irritants causing a swelling of the mucous mem- 
branes of the bronchial tubes, really an urticaria. This 
swelling of the mucous membrane of the bronchial 
tubes has been* caused by injections of horse serum. 

CAUSES 

The diseased condition, or neurosis, termed true 
asthma, is often due to irritation of the nose and 
throat, and sometimes of the ear; is frequently due to 
chronic bronchitis, often is concomitant with acute dis^ 
turbances of the mucous membranes of the upper air 
passages, as when caused by irritations from pollen, 
such as hay fever, rose fever, and by various dust' and 
drug irritants. Asthma, however, is frequently a sim- 
ple respiratory neurosis. 



238 SYMPTOMATOLOGY OF ASTHMA 

SYMPTOMATOLOGY 

An attack of asthma generally occurs at night, and 
may be preceded by headache, some symptom of indi- 
gestion, mental depression or nervous irritability. 
There is at first some slight dyspnea and a short dry 
cough. The dyspnea and consequent cardiac distress 
increase, and the agony suffered by these patients can 
not be understood unless one has seen them suffering 
from an attack of this terrible disease. The agony is 
almost as great as that of acute cardiac dyspnea, 
although there is not much mental anxiety. The 
patient may be. pale or almost livid, and the expression 
of the face shows the suffering due to attempts to 
inspire, and then to expire, through the contracted 
bronchial tubes. The muscles of inspiration being 
stronger than the muscles of expiration, for a time 
more air enters the lungs than can get out, and little 
by little there is increased chest distention. Percussion 
shows hyper-resonance. The greatest amount of 
wheezing, as shown by the stethoscope, is in expiration, 
and the expiration is prolonged in the attempt to empty 
the lungs and prepare them for the next inspiration. If 
the bronchial secretion begins, as it generally does, 
moist rales may also be heard, and, after a series of 
spasmodic efforts, the cough brings up white glairy 
mucus. 

The length of these attacks of acute asthma, if unre- 
lieved, varies from an hour or two to all night, and 
sometimes an attack may last several days. Occasion- 
ally the attacks last for many hours, or even days, in 
spite of all treatment, and any temporary relief given 
by powerful drugs may not prevent the resumption 
of the asthmatic spasm the moment the patient is out 
of the influence of the drug. The amount of dyspnea 
that the patient has, and the amount of suffering and 
the seriousness of the attack, do not bear a close rela- 
tion to the amount of wheezing that is heard. A 
patient may not suffer greatly from dyspnea so long 
as he is sitting upright, and yet be wheezing like a 
decrepit old horse. 

The longer the paroxysm lasts and the more intense 
it is the greater the danger of permanent injury to 
the heart and the greater the danger of the distention 



TREATMENT OF ASTHMA 239 

of the chest so injuring the lung tissue as to make 
the emphysema permanent. Even after repeated 
attacks most patients have no cardiac injury and no 
lung injury, but this is doubtless because most of those 
who suffer from acute asthma are young; the older 
patients do have more or less lasting bronchitis, heart 
debility and more or less constant dyspnea and often 
emphysema. It is rare for a patient to die during an 
attack of acute asthma, but the condition should always 
be considered serious, as it could never be decided 
how much future disability was caused by the pro- 
longation or repetition of such serious disturbance of 
the vital functions of respiration and circulation. 

Acute attacks of asthma may occur every night for 
a series of nights, and then not for a long period, or 
after one attack there may be no more for some time, 
or they may occur more or less periodically, or they 
may recur only at certain periods of the year or in 
certain places. These last are likely to be due to nasal 
irritations. The attacks may also occur more or less 
frequently for several years, or even for a lifetime. 

GENERAL* TREATMENT 

The opinion is gaining ground that asthma is a form 
of anaphylaxis. The physician should endeavor to 
ascertain what type of hypersensitiveness each case 
presents. 

Gottlieb (Jour. A. M. A., 74, 931, April 3, 1920) has 
outlined the form for a systematic examination in 
these cases which is quite suggestive. There should 
come first examination of the nose, throat and teeth 
and roentgen-ray examination of the head to determine 
the presence or absence of pituitary enlargement, and 
disease in the alveolar processes of the jaws. Search 
should then be made in other parts of the body for 
infected areas or absorption of toxic material, such as 
may occur from a diseased appendix, gallbladder, pros- 
tate, ovary, etc. Bacteriologic examination of the 
nasal discharges, pus from the tonsils and tooth sockets, 
bronchial secretions and stool should follow. Suspen- 
sions of the individual bacteria isolated from the vari- 
ous secretions and discharges should be prepared for 



240 SENSITIZATION IN ASTHMA 

the purpose of making skin tests. These skin tests are 
also to be made with stock bacterial proteins, epider- 
mal and food proteins, and pollens. 

The treatment of this troublesome disease, or condi- 
tion, will never be a success unless the cause has been 
determined, and, if possible, removed. Hardly any 
patient with any disease should receive a more careful 
general examination than the asthma patient. The 
lungs must be carefully examined for bronchitis and 
emphysema, and more serious conditions found or 
eliminated, and the blood pressure taken. The diges- 
tive ability of the stomach and intestines should be 
investigated, the urine should be examined, and all pos- 
sible reflex causes sought in the throat, nose or ears. 
If all tangible causes of the asthmatic attacks have 
been eliminated, a careful analysis of the excretion of 
the various salts and solids in the twenty-four hours' 
urine, on a known diet, should be made. Even careful 
examinations of the feces, on a known diet may give 
conclusive evidence of the cause of the toxemias that 
give rise to asthma. Finally the response to cutaneous 
sensitization tests with various food substances pre- 
pared as vaccine for this purpose may be thoroughly 
studied with a view to finding some substance to which 
the patient has an idiosyncrasy. 

SENSITIZATION 

According to I. Chandler Walker (Jour. A. M. A., 
Aug. 4, 1917) bronchial asthmatics who are sensitive 
to specific substances have the onset of their asthma 
early in life, are not usually subject to chronic bron- 
chitis nor to cardiorenal disease. Those not sensitive 
have asthma after 40 years of age and have the two 
complications mentioned. The sensitive patient will 
usually be found to respond with a positive skin test 
to one of the following kinds of protein: horse dan- 
druff, staphylococci, wheat, pollens, cat hair and a few 
very common foods. The skin test is made as follows : 
"A number of small cuts, each about one-eighth of an 
inch long, are made on the flexor surfaces of the fore 
arm. These cuts are made with a sharp scalpel, but 
are not deep enough to draw blood, although they do 



DRUGS IN ASTHMA 241 

penetrate the skin. On each cut is placed a protein 
and to it is added a drop of tenth normal sodium 
hydroxide solution to dissolve the protein and to per- 
mit of the rapid absorption. At the end of a half 
hour the proteins are washed off and the reactions are 
noted, always comparing the inoculated cuts with nor- 
mal controls on which no protein is placed. A positive 
reaction consists of a raised white elevation or urti- 
carial wheal surrounding the cut. The smallest reac- 
tion that can be called positive must measure 0.5 cm. 
in diameter. 

DRUGS IN ASTHMA 

Perhaps the most frequently successful drug in pre- 
venting the recurrence of asthma is an iodid, and this 
is probably because most asthma is due to affections of 
the air passages, and this drug is specifically a stimu- 
lant to the mucous membrane of the nose, throat and 
bronchial tubes. If any chronic disturbance is located 
in these mucous membranes the iodid tends, first, to 
increase the exudate from these membranes, then to 
make the mucus more liquid, and, while at first appar- 
ently irritant, soon relieves congestion of these mem- 
branes, and often, sooner or later, cures a chronic con- 
gestion and causes the membrane to become healthy. 
Hence the frequency of success from iodid simply 
emphasizes the necessity of a careful examination for, 
and the removal, if found, of any nasal obstructions 
or irritations. After such removal, a sensible treat- 
ment to prevent the recurrence of attacks would be 
the prolonged administration of iodids, and very large 
doses are seldom needed, or if the history of the attack 
shows long standing of the disease, the -treatment of 
the neurosis by bromids is advisable, and here again 
the dose should not be large. We should not produce 
debility either with iodids or with bromids. 

Arsenic seems at times to have a specific action. In 
chronic bronchitis, in asthma, and in catarrhal condi- 
tions of the upper air passages, arsenic, when given for 
a long period, is sometimes of considerable benefit. 
The respiratory ability and freedom from colds and 
coughs of the arsenic eaters of France and the Alps 
is well known. 



242 TREATMENT OF ASTHMA 

A local cause in the upper air passages having been 
removed, if there was any such, besides treatment 
either by iodids or bromids, if either one is deemed 
advisable, anything that will improve the general health 
of the individual should be utilized. An occupation in 
which there is an atmosphere of dust or other irritant 
should be changed for one more suitable. Perhaps 
indoor work should be changed for outdoor work, per- 
haps the climate or location should be changed. Any 
indigestion, gastric or intestinal, should be corrected; 
constipation should be prevented; anemia should be 
treated, and insufficiency of the thyroid, if present, 
should be noted and modified. 

If asthma occurs at certain periods of the year as 
does hay fever, the preventive treatment is the same 
as for hay fever. Anything that will reduce the nasal 
irritations and congestions will relieve the asthma, and 
any change in location that will prevent the hay fever 
will generally prevent the asthma. To just what local- 
ity or climate an asthmatic patient should be sent is 
difficult to determine. Also it is impossible to predict 
that, because one patient is benefited by a sojourn or 
residence in one particular place, that place will be 
beneficial to the next patient. Theoretically, regions 
free from dust and vegetation should be the regions 
to prevent attacks of asthma. Sea voyages are some- 
times beneficial and sometimes not. The decision as 
to whether or not benefit will be derived from certain 
regions may often be determined by a careful investi- 
gation into the condition of the patient's mucous mem- 
branes and the condition of his circulation. 

Anything that would tend to make the circulation 
better in the mucous membranes of the upper air pas- 
sages and diminish congestion and tumefaction of the 
mucous membranes of all the air passages will tend to 
prevent recurrences of asthma. Cardiac insufficiency, 
of course, should be properly treated, and whether the 
heart needs digitalis or the arteries need nitroglycerin 
or nitrites continuously, or whether the general good 
effect of ergot on the circulation is needed (and asthma 
may sometimes be prevented by ergot) must be deter- 
mined by a careful study of the individual patient. 



PAROXYSMS OF ASTHMA 243 

Insufficiency of the kidneys as a cause of asthma 
should be treated by the proper diet and the preven- 
tion, if possible, of nitrogenous toxemias. Such 
asthma is an indication of nitrogenous poisoning. The 
asthma due to gout is often best combated with thyroid, 
and when there is insufficiency of the thyroid in young 
individuals, which may be recognized by well-known 
signs, such as amenorrhea or scanty menstruation in 
women, an unusual and undesirable increase of fat, 
a dry condition of the skin, and a tendency to nitrogen- 
ous poisonings, the asthma will be benefited by small 
doses of thyroid, perhaps, coincidentally administered 
with small doses of iodid, as iodid has been shown to 
be the most active stimulant of the thyroid gland. 

TREATING THE PAROXYSM 

The best treatment of the paroxysm of asthma must 
be decided by a careful study of each individual 
patient. There is no one best treatment for the 
asthmatic attack. The drug that most frequently is suc- 
cessful in rendering the patient comfortable and short- 
ening the paroxysm is, of course, morphin, but before 
the physician begins the treatment of the asthmatic 
attacks with morphin he should have exhausted his 
other resources, as he is not sure that he can cure the 
asthma, even if he removes the reflex cause, and such 
patients readily acquire the morphin habit. If a given 
patient is incurable under the surroundings and condi- 
tions in which he must live and no other drug will 
relieve his suffering, he doubtless has the right to 
receive morphin, even if he does form the habit. 

In endeavoring to abort or shorten the attacks we 
may have recourse to narcotics,' which relieve the 
paroxysm by inhibiting the reflexes and dulling the 
receptive centers. Such drugs are morphin, bromids, 
chloral, and chloroform by inhalation. 

Macht and others have reported that benzyl benzoate 
given by mouth was capable of producing relaxation of 
the bronchial spasm in patients suffering from true 
asthma. Not all cases of asthma respond equally well 
but in some cases the beneficial effects were pro- 
nounced. 



244 TREATMENT OF PAROXYSMS 

We may use drugs that dull the peripheral nerves 
and prevent their susceptibility to the irritation from 
which they are suffering and thus abort the paroxysm. 
Such drugs are mostly of the atropin group, as bella- 
donna, stramonium and hyoscyamus. The effective 
action is atropin action, and doubtless atropin, and per- 
haps scopolamin (hyoscin) will do all the good that 
the crude drugs can do, although inhalation of the 
fumes from burning stramonium leaves has been used 
with success for centuries. 

We may consider the treatment with such drugs as 
cause muscular relaxation by prostration. Such are 
emetics, and tobacco with patients who are not used to 
its action. 

The next group of drugs whose action we consider 
in the treatment of asthmatic attacks are vasodilators. 
These drugs not only dilate the peripheral blood vessels 
and therefore relieve congestion in the mucous mem- 
branes of the respiratory tract, but also are preventers 
of muscular spasm. Such are, of course, the nitrites 
in the form of amyl nitrite, sodium nitrite, and nitro- 
glycerin. The iodids will also cause lowered blood 
pressure, but are hardly of value during the attack. 

Many times quite the reverse of this dilating, relax- 
ing treatment is indicated in an asthma paroxysm. The 
vasoconstrictors are indicated, and if used in these 
instances will abort the attack. The best are solutions 
of epinephrin sprayed on the mucous membranes of 
the nostrils or throat, or into the larynx, or an epineph- 
rin preparation in tablet form may be dissolved and 
absorbed in the mouth. The action is of course imme- 
diate, and sometimes so is the relief. For the nos- 
trils epinephrin spray solutions of from 1 to 10,000 to 
1 to 5,000 (diluting with a mild alkaline solution) may 
be used. In the throat and larynx a strength of 1 to 
3,000 may be used. Digitalis is sometimes of advan- 
tage in these attacks even if there is no cardiac lesion 
or cardiac debility. Intramuscular injection of ' an 
aseptic preparation of ergot is also sometimes efficient 
treatment in stopping the paroxysm. 

Citrated caffein, or strong coffee, or strong decoc- 
tions of tea are of benefit during the asthmatic attack 
in some individuals. The favorable action of caffein 



INHALATIONS FOR ASTHMA 245 

must be due to the cardiac stimulation and possibly to 
stimulation of the respiratory center. 

Strychnin given hypodermatically has been much rec- 
ommended for the asthmatic attack. While it generally 
fails, it sometimes does a great deal of good to patients 
who have bad heart action. A combination of strych- 
nin, morphin, and atropin given hypodermatically 
sometimes seems to act better than when the strychnin 
is omitted. 

INHALATIONS 

Almost from ancient times paroxysms of asthma 
have been treated by the inhalation of fumes from 
burning medicinal substances. For this purpose the 
medicated substance may be in the form of cigarettes, 
powder, cones, or papers. Sometimes the fumes of 
these burning powders are directly inhaled, or the 
patient's bedroom is allowed to become filled with the 
fumes. Sometimes the attack is relieved by the inhala- 
tion of steam, or the vapor of boiling water in the 
room of the patient adds some relief. Sometimes 
liquid medicaments are added to boiling water in vari- 
ous apparatus for inhalation. Most popular, however, 
and most frequently used are the powders or papers, 
or pastils that are burned and inhaled directly. 

Probably nearly all the powders or papers ordered 
by physicians for inhalation for asthma and almost all 
of the patented preparations and nostrums contain 
niter (saltpeter) and stramonium, or belladonna, or 
other atropin-containing drug. The action of the niter, 
i. e., potassium nitrate, fumes is to cause relaxation 
both of the blood vessels and of the bronchi. Papers 
are saturated with solutions of potassium nitrate, and 
when dry may be rolled in the form of a cigarette and 
smoked, or may be burned in any other form, and the 
fumes are beneficial to some patients. The addition of 
potassium nitrate to other medicinal powders causes 
them to burn more readily and give off their fumes. 

Stramonium (leaves) is the most frequent form in 
which the alkaloid atropin is administered by inhala- 
tion. The action of the atropin thus locally applied is 
to dull the irritability of the peripheral nerves in the 
nose, throat and larger bronchial tubes, and thus by 



246 PROTEIN IMMUNIZATION IN ASTHMA 

relieving irritation it tends to relieve spasm. At the 
same time the atropin acts as a circulatory stimulant. 
Various combinations of drugs are used for inhala- 
tion for asthmatics, many of which are nostrums (but 
have been analyzed) and have more or less efficiency 
in relieving the attack,, because of the potent drugs 
often recklessly employed. The asthma nostrum ven- 
dor is looking mainly for immediate results, and he 
cares little what the danger to the patient may be or 
how strong a dose he gives; consequently, he orders 
sufficient amounts of the drugs to cut short the 
asthmatic attack. Therefore, the prescription which 
a physician is willing to write may not be so successful 
in a certain case as the nostrum temporarily may be. 

PROTEIN IMMUNIZATION 

Walker found that asthmatics who were sensitive 
to proteins in horse dandruff or cat hair were relieved 
of attacks during a series of subcutaneous injections 
with these proteins. Treatment was begun with a 
dilution of the protein next higher than that to which 
the patient reacts, sometimes as high as 1 : 100,000. 
The strength of the dilution is then slowly and grad- 
ually increased waiting for a subsidence of response 
following each injection. The largest number of 
doses required was forty-two, the average number was 
eleven. The protein extracts are injected intramuscu- 
larly with all of the precautions that accompany any 
surgical procedure, including thorough cleansing of 
the skin, sterilization of the syringe by boiling, and 
absolute surety that the injection is not being made' 
directly into a blood vessel. 

Oxygen inhalations have sometimes been used by 
asthmatics, and with relief. This, however, is not 
very dissimilar to breathing the outside air, and will, 
of course, partly relieve the oxygen starvation. A 
patient who must go to the window and gasp for 
breath should, perhaps, have an oxygen tank in his 
room to use when he needs it. 

If we were to sum up the best treatment for the 
paroxysm of asthma we must say morphin and atropin 
hypodermatically, the administration of nitroglycerin 



HAY FEVER 247 

by the mouth, or epinephrin into the nostrils or throat, 
or tablets containing epinephrin dissolved in the 
mouth, and fumigations with potassium nitrate and 
stramonium. 

HAY-FEVER 

This troublesome condition is most frequent in the 
late summer and early fall months, but it may occur 
at other times of the year in different climates, 
depending on the susceptibility of an individual to 
various pollen-bearing plants. \Vhile bacteria may 
increase the intensity of the disease, or may cause a 
patient to become susceptible to it, still hay-fever is 
probably always caused by irritating pollen. 

The disease is present only in regions where pollen- 
rich plants predominate, and occurs only when these 
plants have reached the stage of disseminating the 
pollen, or when the pollen is artificially introduced 
into the nostrils of a susceptible person. When a 
patient is removed from all source of pollen, or when 
the offending weeds are destroyed in the region in 
which the patient lives, hay-fever does not occur. 

Hay-fever is no respector of persons, and may occur 
at any age, in both sexes and in any civilized race. It 
is more frequent, however, in males, and more fre- 
quent in the white race than in the colored race. The 
age of greatest susceptibility, or the age at which 
most cases develop! seems to be in the decades from 
10 to 40. This age of greatest incidence and the rea- 
son that males are more affected than females may 
signify the age and sex most exposed to pollen. 

Scheppegrell, president of the American Hay-Fever 
Prevention Association, finds that hay-fever may be 
artificially produced at any time in hay-fever subjects. 
If the inoculation of the irritating pollen, which he 
finds to be the male elements of the flowering plants, 
is given to the patient at another period of the year 
than the hay-fever season, the length and degree of 
the attack may be accurately controlled. This is 
because, unlike micro-organisms, the male elements of 
these pollens cannot reprpduce themselves. 

The reaction from these pollens he divides into the 
direct and indirect effect. Some produce the reaction 
by the local mechanical irritation, and this perhaps 



248 PREDISPOSITION TO HAY FEVER 

even in persons not susceptible to hav-fever. In 
insusceptible subjects, the reaction ceases as soon as 
the pollens are discharged. The indirect effect occurs 
in susceptible persons who are poisoned by absorption 
of some toxalbumin contained in the pollen. 

While the pollen of many plants may cause hay- 
fever reaction when applied directly to the nostrils, it 
is only the wind-borne pollens that need to be consid- 
ered in hay-fever. Scheppegrell states that it is char- 
acteristic of hay-fever weeds that they have no attrac- 
tive flowers or perfumes, and these hay-fever plants 
are "the ragweeds, wormwoods, cockleburs, careless 
weeds and grasses." In the United States, the spring 
type of hay-fever is caused by the grasses, while the 
fall types are caused more by the ragweeds, the cockle- 
burs and the wormwoods. While it seems to be a 
fact that goldenrod is a cause of hay-fever, Scheppe- 
grell doubts that it is a frequent cause. 

SUSCEPTIBILITY AND PREDISPOSITION 

There can be no question that a susceptibility to 
hay-fever must exist since so few persons ( 1 per cent., 
according to Scheppegrell) in a locality overrun with 
these weeds are subject to the affliction. 

Cook, Flood and Coca {Jour. Immunol., \9\7, 2, 
217) after careful investigation of the subject of sen- 
sitization, sum up thus: 

1. Hay-fever is the clinical symptomatic expression of local 
hypersensitiveness. The active pollen substances are not 
toxins. 

2. The hypersensitiveness is established spontaneously and 
never by immunologic process. This has been shown in two 
ways: first, by the observation that individuals may be 
sensitive to pollens of plants that are indigenous in foreign 
countries and with which they have never come in contact; 
and second, by the observation that individuals who are 
naturally sensitive to one protein only cannot be artificially 
sensitized to another protein, either animal or vegetable. 

3. The sensitization is not directly inherited, although the 
tendency to spontaneous sensitization is inherited as a domi- 
nant character. 

4. The antibody-like substances of human sensitization are 
not demonstrable in the blood of sensitive persons by any of 
the immunity reactions. They are present in the cells. of the 



SUSCEPTIBILITY TO HAY FEVER 249 

sensitive tissues. They cannot be increased artificially by 
the usual process of immunization. 

5. The mechanism of the alleviating effect of specific, that 
is, pollen extract therapy, is the same as that of desensitiza- 
tion in experimental anaphylaxis. The freedom from symp- 
toms lasts as long as the respective "antigenic" substances 
remain in combination with the antibody-like substances in 
the tissues. 

Persons who are attacked by hay-fever may be pre- 
disposed by some other cause than a peculiar hyper- 
sensitiveness of the mucous membrane of the nose. 
These patients, many times, are found to have ana- 
tomic malformations, such as hypertrophic turbinates 
or deviated septums, or other obstructive or irritative 
conditions in the nostrils, and many of these patients 
are cured by the removal of these abnormal condi- 
tions. In other instances more or less incurable 
pathologic changes may be present in the mucous 
membrane of the nose and adjacent sinuses. Further- 
more, a neurotic individual may be more hypersensi- 
tive to this irritation than other persons without any 
assignable physiologic, pathologic or anatomic excuse. 

On the other hand, as shown by Strouse and Frank 
(Jour. A. M. A., March 4, 1916, p. 712), persistence 
of a hay-fever attack may well be due to an associated 
bacterial acute or subacute infection. An associated 
infection may allow more of the pollen irritant to 
become absorbed, and the disease is then intensified 
and is more difficult to cure. Continuing their studies 
they have confirmed their earlier impressions (Jour. 
A. M. A. 74: 1593, May 11, 1920) that it is important 
first to clear up all anatomic deformities of the nasal 
tract, then to correct local infections and then to admin- 
ister combined pollen and vaccine treatment. 

Hay-fever due to pollen should be differentiated 
from similar conditions caused by emanations from 
animals, such as the horse, cat or dog, and from 
odors from certain fruits, flowers, and from ipecac 
and musk. Sneezing, lacrimation, coughing and 
asthma may occur in some persons, who have such 
peculiar idiosyncrasies. Bronchial asthma may occur 
as a separate entity, or be associated with or follow 
hay-fever; hence its treatment often is the same as 
that of the hay-fever. 



250 GENERAL TREATMENT OF HAY FEVER 

The symptoms of an attack of hay-fever may begin 
immediately on inhalation of the pollen, or they may 
be delayed for a few hours; but sneezing, congestion 
of the nostrils, reddening and itching of the eyelids 
or of the inner canthi of the eyes, irritation of the 
roof of the mouth and throat, and soon more or less 
spasmodic attacks of sneezing are the primary symp- 
toms. Later rhinitis may occur, with more or less 
conjunctivitis, pharyngitis and bronchitis. There may 
be temporary increased temperature, but soon there is 
depression, more or less weakness, and often sub- 
normal temperature. 

GENERAL TREATMENT 

1. All predisposing causes should be ascertained, 
and if possible, removed. 

(a) Hypertrophic and sensitive mucous membrane 
of the turbinates should be removed. An obstructive 
and deflected septum should be corrected. An infected 
sinus should be cleaned. 

(b) All infected areas in the mouth and throat 
should be removed. 

(c) Meat and purin bases should be removed from 
the diet. Although the diet should be nutritious, it 
should contain no irritating substances, such as mus- 
tard or other condiments. Tea and coffee are contra- 
indicated. Fish, strawberries, and any other food that 
is likely to cause anaphylactic irritability should not 
be allowed. 

(d) The bowels should be carefully regulated so 
that toxic intestinal substances are prevented from 
entering the circulation and adding to the disturbing 
elements already present in the blood. 

(e) Alkalis should be administered to decrease any 
possible hyperacidity of the system. There is no bet- 
ter alkali than sodium bicarbonate, which should be 
administered for a few days at least in a dose of 1 
gram (15 grains) every three hours. It is pleasantly 
given as an effervescing salt. 

If preferred, potassium citrate may be the salt 
administered. The dose should be 2 gm., given in 
wintergreen water, and administered four times a day. 
There is no question that alkalis many times diminish 



CALCIUM IN HAY FEVER 251 

the irritability caused by anaphylaxis, and it has long 
been recognized that alkaline sprays in the nostrils 
are of benefit, and alkaline gargles are soothing, in 
hay- fever. 

(/) Calcium is often of value in hay-fever, as it is 
in hives, in angioneurotic edema, and in some forms 
of asthma. Calcium may be administered as calcium 
lactate, or as the more irritant calcium chlorid. If the 
lactate is used, and especially if the chlorid is used, it 
should be administered after food has been taken, and 
then largely diluted. 

(g) An associated bronchitis should be treated as 
though the hay-fever were not a factor. 

(h) A weakened heart should be strengthened. 
The persistent sneezing and the frequent coughing in 
hay-fever always more or less weaken and tempo- 
rarily, at least, dilate a heart, and a hay-fever patient 
generally is improved by digitalis. Of course, if the 
heart is sturdy, if there is arteriosclerosis and hyper- 
tension, digitalis may not be indicated, and nitro- 
glycerin may be of value. Strychnin is generally 
inadvisable, on account of its increasing the general 
nervous irritability. 

2. If possible, all pollen-bearing weeds in the imme- 
diate neighborhood of the patient's home should be 
destroyed ; otherwise the patient must migrate to some 
pollen-free region. 

3. The symptoms should be ameliorated. Most 
patients certify to the relief obtained from simple 
alkaline sprays in the nose and throat. Such treat- 
ment is well represented by alkaline tablets, consisting 
essentially of sodium bicarbonate and borax, dissolved 
in 60 c.c. (2 fluidounces) of warm water. Epi- 
nephrin sprays, in solution of 1 : 10,000, are used, 
and are frequently of value. It may also be used as 
an ointment of 1 : 1,000, and a small portion placed in 
each nostril. Some persons, while getting immediate 
relief from epinephrin solutions, later have increased 
congestion and extra sneezing, but the majority of 
patients are benefited. Sometimes a weak menthol, or 
menthol and camphor, oil spray or ointment benefits 
the patient. While cocain may be -used by the phy- 



252 SPECIFIC TREATMENT OF HAY FEVER 

sician in his office, if he thinks it advisable in an indi- 
vidual case, such solutions should not be given to the 
patient, and should not be used frequently by the 
physician. Boric acid washes and eyedrops will gen- 
erally relieve the itching of the eyes and eyelids and 
will be soothing in conjunctivitis. If the nasal dis- 
charge is very profuse and watery, atropin sulphate 
in a dosage of 1/500 grain every two hours may be 
given until there is a dryness of the throat. 

If there is much asthma and the patient wheezes 
and has hard work to get his breath, and the bronchial 
secretion is not sufficient, sodium iodid in a small dose 
to cause an increased secretion may be good treat- 
ment, although it will almost invariably increase the 
nasal secretion. 

4. The only drugs that have proved of much value 
in hay-fever are quinin and antipyrin, and these are 
not very efficient. Large doses of quinin have been 
found successful in some cases. Antipyrin in large 
doses has also modified the attacks, much as it may 
modify the paroxysms of a whooping cough; but the 
doses must be large, and during its administration the 
heart should be protected by digitalis. Arsenic and 
strychnin have been advocated, but have not been 
proved of much value. 

SPECIFIC TREATMENT 

Preventive. — Before it is decided to use a pollen 
extract, it is advisable to ascertain the particular 
pollen to which the patient is susceptible. The skin 
test is safe and generally satisfactory; the eye test is 
hardly justifiable. Various dilutions of different pol- 
len extracts should be tried in this test. The arm 
is generally employed for this purpose. Several 
scratches through the epidermis are made, and a drop 
of the pollen extract, beginning with a well diluted 
solution, of first one hay-fever weed and then another, 
is used to note the sensitivity. A patient sensitive to 
an extract soon shows local irritations at the point of 
absorption. As soon as the pollen that causes reaction 
is found (the reaction occurring in from five to fifteen 
minutes), various dilutions of this particular pollen 



POLLENS IN HAY FEVER 253 

may be tested to determine the dose correct for this 
particular patient, and the first dose of injection should 
be the dose which fails to excite a skin reaction. The 
first subcutaneous injection should not be given until 
after all symptoms of the local skin test reaction have 
subsided. 

As it is not always feasible to test out the individual 
pollens as described above, the stock preparations of 
mixed spring or fall pollens may be used. Full direc- 
tions for the use of these pollen extracts for diagnostic 
purposes, for immunization, and for curative purposes, 
come with the package. 

The preventive treatment of hay-fever should be 
begun about eight weeks prior to the season in which 
the patient is susceptible. Ordinarily from ten to 
fifteen injections are required, and they should be 
given at two or three day intervals, depending on the 
amount of reaction. If symptoms of anaphylaxis or 
hay-fever symptoms occur, the dose should be smaller 
and less frequent. If the patient, from such injec- 
tions, is immune for that year, he may be immune to 
the hay- fever pollen the following year; but it seems 
to have been shown that this immunity is only weak 
and rather ineffective by the third year. However, 
sufficient statistics have not yet been offered to show 
how long an immunity may last; also failure to pro- 
duce immunity must be expected. Strouse and Frank 
find the immunity gradually increasing from year to 
year. The theory of this treatment is that a person 
sensitive or sensitized to a certain pollen may be desen- 
sitized by exhausting from the body cells the specific 
proteolytic enzymes by the pollen protein injection. 

Curative. — Not enough data have been presented to 
show the value of the vaccine and pollen treatment 
during the active process of hay-fever. 

It would be inadvisable, however successful in indi- 
vidual cases the pollen treatment might prove to be, 
to omit the therapeutic suggestions already mentioned. 
It would also be inadvisable to depend on possible 
immunization for the following year by means of pol- 
len extracts and to omit a careful study of the patient 
to eliminate, if possible, all predisposing causes of 
hay-fever disturbances. 






DISEASES OF THE GASTRO INTES- 
TINAL TRACT 



HYGIENE OF THE MOUTH AND TEETH 

The things to be remembered in the care of the 
mouth and teeth may be summed up as follows: 

1. Theoretically water should follow the milk of 
bottle-fed babies. 

2. A soft cloth should be thoroughly moistened with 
a mild alkaline wash and frequently applied over the 
first little teeth of the infant. 

3. No candy, or at least but little, should be given 
to young children, and as soon as their teeth have 
erupted they should have the more crunchy or granular 
cereals, and not so much of the soft, gelatinous cereals. 

4. The teeth should be regularly cleaned by a den- 
tist, at least once in six months. 

5. All cavities, even small, should be filled, at least 
with temporary filling, so that the first teeth may be 
preserved as long as possible in order to develop the 
jaws properly, so that the second teeth need not be 
crowded. 

6. The teeth of children and adults should be thor- 
oughly brushed at least twice a day, better three times, 
with a proper brush, and, at least in the morning, with 
a tooth powder that is not too soapy, and at night with 
an alkaline mouth wash. Tooth brushes must be clean. 

7. All persons, growing children or adults, should 
have all the tartar that may become deposited cleaned 
from their teeth once in three months, and examina- 
tions of the teeth once in every six months will disclose 
small cavities before they have become large ones. 

8. If the teeth tend to degenerate and cavities 
quickly form, the trouble is generally with the nutri- 
tion, and the person is often deficient in bone-forming 
salts. Such patients should receive lime salts, phos- 
phates and iron. 

The best iron preparations for this purpose are: 
tinctura ferri chlorid, 1 or 2 drops in a wineglass of 



HYGIENE OF THE MOUTH 255 

water or fresh lemonade, three times a day, after 
meals; ferrum reductum 0.05 gram (1 grain), in 
capsule, three times a day, after meals ; ferri oxidum 
saccharatum tablets, each 3 grains, 1 three times a day, 
after meals. 

If the teeth are delayed in eruption and do not grow 
properly in young children, the dried extract of the 
thymus gland may be of value. One of the tablets is 
given three times a day ; it is best taken between meals, 
crushed with the teeth and swallowed with water. 

If the child as a whole does not grow well, even if 
not a cretin or if he is in any way like a cretin, small 
doses of thyroid extract (thyroideum siccum) in dose 
of 0.03 gram (% grain) once a day, are of value, and 
this dose is sufficient. 

9. The care of the mouth during severe illness 
should be on the lines previously described. 

10. The proper care of the teeth will prevent pyor- 
rhea, and infection, which is a menace to health. 

11. The treatment of pyorrhea alveolaris must be 
strenuous and persistent. There is no excuse for its 
presence, and it can be eradicated. The treatment is 
persistent cleanliness and antisepsis, the same as in 
ozena. There is no excuse today for the horrible 
stench perpetrated by patients who suffer from ozena. 
The same is true of the nastiness of the breath of 
these pyorrhea patients, to say nothing of the danger 
to themselves of infection from germs harbored in the 
mouth. The elementary features of the treatment 
include a frequent use of a mouth wash of 1 part 
of peroxide of hydrogen solution in 4 or -5 parts of 
warm water, and then the persistent use of an anti- 
septic alkaline mouth wash and tooth paste or tooth 
powder after the peroxide of hydrogen has eradicated 
and removed the pus. 

MOUTH INFECTIONS 

Only of late years has the part played by the mouth 
and its adjacent structures in the production of a great 
many pathologic processes has been demonstrated. The 
mouth, including the teeth, gums and tonsils, affords a 
broad surface and readily accessible means of entry 



256 MOUTH INFECTIONS 

for various pathogenic micro-organisms. It is not 
always essential that visible evidence should be pres- 
ent in the mouth of the focus producing a systemic 
infection, to prove that the portal of entry is in the 
mouth. The focus may be discovered only by careful 
examination with the roentgen ray. A portal of 
entry may be present and not directly demonstrable in 
any way, for example, when the bacteria enter the 
lymph or blood stream by way of the tonsils. That 
a focus does exist in the mouth and that it is directly 
responsible for the pathologic condition has been 
repeatedly proved by removing the source of infec- 
tion or by treatment with a proper autogenous vaccine 
made from bacteria isolated from the pus at the site 
of the focus. Such treatment often causes the disap- 
pearance of the systemic pathologic condition. 

Within the mouth there are various channels 
through which bacteria may enter the system: the 
tonsils, gums, roots of the teeth, and by way of the 
esophagus to the stomach and intestine. That the ton- 
sils play an important part in various infections has 
been demonstrated. 

In this connection, the work of Rosenow has proved 
that many ulcers of the stomach are associated with 
tonsillar infections. He obtained streptococci from 
some of these ulcers, and after injecting cultures of 
these organisms into animals, he was able to observe 
gastric ulcers in them. Stone pointed out the rela- 
tion between enlarged cervical glands and foci of 
infection of the tonsils," even though the tonsils may 
not be hypertrophied or inflamed. The short and 
direct communication between the tonsils and the 
lymphatics is responsible for this. In this way there 
may also result tuberculous adenitis. Infected teeth 
and tonsils are frequently the cause of endocarditis. 

Perhaps equally common as a source of infection 
are the teeth. The open, exposed, ulcerated or 
decayed tooth is not always the worst in this respect. 
More harm may be done by the heavily crowned, 
capped and bridged teeth, under the poorly fitted mar- 
gins of which the bacteria flourish and manage either 
to enter the lymphatics or to send their toxins into 
the system. There may also be a tiny abscess situ- 
ated deep down at the root of the tooth. In these 



TREATMENT OF MOUTH INFECTIONS 257 

cases local manifestations of a focus in the teeth may 
be entirely lacking, and may be demonstrable only by 
the roentgen ray. These so-called "blind-abscesses" 
may remain dormant a long time. Ultimately they 
open into the mouth by way of a sinus. Often they 
lead into larger abcesses in the bone, in which toxins 
are produced, giving rise to septic conditions. Depend- 
ing on the nature of the organism in the abscess, there 
may result any of the complications so often resulting 
from tonsillar affections. Rosenow states that these 
foci are common in patients who for years have suf- 
fered from arthritis, neuritis, appendicitis, ulcer of the 
stomach, goiter, etc., and that persons with perfect 
health are, as a rule, free from sources of infection in 
relation to the teeth. 

The treatment of the complications secondary to the 
focus within the mouth consists first of all in remov- 
ing the mouth infection. Careful examination should 
be made of the tonsils and teeth, and if the tonsils 
are found to be hypertrophied or inflamed, even with- 
out visible signs of any abscess, they may be removed. 
Often the abscess may be located deep in one of the 
crypts. If any visible pus is present, it would be 
advisable to obtain a culture of the bacteria contained 
in it. Normal tonsils should not be removed. When 
the tonsils appear normal, even though there may be 
no history of tooth involvement, the teeth, neverthe- 
less, should be carefully examined. Poorly fitting 
crowns should be taken off, and often underneath 
them may be found the cause of the trouble. Many 
cases of arthritis have been cured by a correction 
of the dental work of the mouth, removal or filling of 
ulcerated areas, and insertion of proper bridge work. 
Roentgenograms may locate a blind or apical abscess 
when least suspected. When such has been found, 
the tooth should be extracted. Rarely it is possible to 
drill into the abscess and in this way offer drainage 
for the pus. In this way also the tooth may be saved. 
Impacted, unerupted teeth are also a frequent source 
of infection. 

Besides the removal of infection foci, a mouth wash 
may be indicated. There are many mouth washes on 
the market under various trade names. Many of these 



258 PREVENTION OF MOUTH INFECTIONS 

contain the same ingredients and vary but slightly in 
theip composition from those described in either the 
Pharmacopeia or the National Formulary. The best 
mouth washes are those that are alkaline, antiseptic 
and astringent. Some of the simpler antiseptic and 
astringent mouth washes are strong solutions of 
glycerin or of alcohol. Hydrogen peroxid, one part, 
to three parts of water is a good wash. For ordinary 
cleansing purposes sodium bicarbonate, in water, will 
serve the purpose. A list of good mouth washes 
appears in a later article. 

Cleanliness of the teeth plays an important part in 
the asepsis of the mouth. By regular and frequent 
brushing of the teeth with a good, fairly stiff tooth- 
brush and a simple tooth powder or tooth paste, the 
accumulation of tartar on and between the teeth may 
be to some extent prevented. In conjunction with 
this brushing of the teeth, gargling with a mouth wash 
will aid in cleansing the mouth. Equally if not more 
important in the care of the teeth is the periodic visit 
two or three times a year to a dentist, that tartar may 
be removed, that caries of the teeth may be early 
treated, and that the condition of the gums may be 
noted and pus pockets early discovered. 

PREVENTION 

Prevention of suppuration or other infection in the 
mouth is of the greatest importance all through life. 
The following suggestions for preventive measures 
may be of value : 

1. There should be inspection of children's teeth in 
schools. 

2. Every infected area in the mouth must be treated 
and eradicated, if possible, as soon as discovered. 

3. The public should be taught that a bad tooth or 
a diseased gum or tonsil is serious, and neglect of 
such a condition may cause an incurable disease. 

4. The mouth of every patient should be examined 
as part of the physical examination. 

5. Roentgenograms of suspected gums or jaws 
should be taken, and if advisable, a culture from the 
pus or secretions of the infected region should be 
made. 



PYORRHEA ALVEOLARIS 259 

< 
6. There should be cooperation of the physician 
with the dentist to decide on what is best for the 
correction of mouth defects, whether certain teeth 
should be filled or pulled, or otherwise treated, and 
just what is the best treatment for a diseased gum or 
tonsil. Neither physician nor dentist is infallible, and 
both should recognize that cooperation is best for the 
patient. 

PYORRHEA ALVEOLARIS 
GENERAL CONSIDERATIONS 

The occurrence of pyorrhea alveolaris varies among 
different classes of people. At present the care of the 
teeth has an important place in the daily routine of 
the better educated people, and although cases do 
exist among them, they are less frequent than among 
those who are strangers to the toothbrush and to 
mouth cleanliness. Bass and Johns state that they 
found pyorrhea in 95 per cent, of the cases examined 
by them. It is possible that their cases were collated 
from the poorer classes of people and from those 
suffering from tooth affections. 

By pyorrhea alveolaris is meant a condition in which 
pus to a greater or less degree is present at the gingival 
margins affecting the peridental membrane and ulti- 
mately exposing the bone. As a result, pus pockets, 
from which pus escapes freely or may be easily 
expressed, occur. Predisposing factors are bad 
crowns, careless fillings, improper bridging, and, in all 
classes, neglect of the care of the teeth. Bacteria find 
a lodging place in the tartar deposited on the teeth or 
under a cap, and set up an inflammation. The gums 
become painful and tender, and there is a tendency 
to bleed easily from the slightest touch. Gradually 
the gums recede until pockets form between the teeth 
and gums in which the bacteria grow and thrive 
unchecked. Unless the disease is stopped, the teeth 
lose their firm support in the alveolar processes and 
become loose. 

Pyorrhea alveolaris, just a local infection around 
the teeth, seems directly responsible for a large 
number of body ailments, produced by the entry 
into the lymph or blood stream of the bacteria 



260 TREATMENT OF PYORRHEA 

from the infected gums. Their toxins also produce 
systemic disturbances. It is also true that general 
systemic infections, by lowering the resistance of the 
gums, may be the starting point of pyorrhea alveolaris, 
which will continue after the general infection has 
been cured. Removal of the pus may cure the asso- 
ciated condition. It is also probable that the pyor- 
rhea, through its micro-organisms and their toxins, 
reduces the physical resistance of the body to such 
an extent that it is readily susceptible to other inva- 
sions. 

There has been considerable difference of opinion 
as to the cause of pyorrhea alveolaris. Fully 150 dif- 
ferent organisms have been isolated from the gums and 
described. It has been assumed by many using vac- 
cines that the real offender was a streptococcus, and 
that if such were obtained from the deep recesses of 
the puspocket, it could be used for the manufacture of 
an autogenous vaccine in the treatment of the condi- 
tion. Hartzell and Henrici found streptococci in cases 
of pyorrhea alveolaris and dental abscess associated 
with arthritis deformans, acute articular rheumatism, 
endocarditis, pernicious anemia, gastric ulcer, and acute 
iritis. Vaccines were used with varying results, but 
these authors cannot positively state that vaccines have 
a definite value in these cases. They also found other 
organisms present with the streptococci. 

Barrett and later Bass and Johns recognized the 
ameba or endameba as the specific micro-organism of 
pyorrhea alveolaris. There seems to be but little doubt 
that Endameba buccalis is a common invader of the 
tissues within the mouth, particularly the gums. 

TREATMENT 

Bass and Johns have recommended doses of 0.5 gm. 
emetin hydrochlorid hypodermically each day for from 
three to six days, the duration depending on the case, 
and also on the stage of the disease: They found that 
the endamebas disappeared from all lesions in 90 per 
cent, of their cases after a one to three day treatment. 

The employment of iodin on the gums is both anti- 
septic and stimulating to the tissue of the gums which 
becomes firmer under its use. Talbot describes this 



FOUL BREATH 261 

use of iodin as follows: A mixture which he calls 
iodoglycerol consisting of zinc iodid, 15, water, 10, 
iodin, 25, and glycerin, 50, is applied with cotton wound 
around wooden applicators to the gum margins above 
and below. The lips and cheeks are held away from 
the jaws until the iodin has dried. These applications 
should be made every day and continued until the 
patient is dismissed. 

Most important in ridding the patient of pyorrhea 
are the services of a good dentist. Whatever the 
local or systemic treatment, the dental management 
of the retracted gums and eroded and diseased teeth 
is of primary importance and any treatment will fail 
unless the dental care is also successful. During such 
treatment Talbot suggests friction and stimulating 
methods be employed by the vigorous use of a "gum 
massage brush" to stimulate the gums. Such a brush, 
he says, should be so shaped that it will reach the 
festoons between the teeth. It should be made of 
the stiffest unbleached bristles that can be obtained. 
The brush should be inserted into the mouth, the 
mouth and teeth closed. When the tissues of the 
mouth have become revitalized, deposits from the 
alveolar process on the roots of the teeth will cease 
to form. As a gum wash for the patient to use in 
connection with gum massage he suggests a zinc car- 
bolate mixture originally recommended by Whitslar: 

Zinc sulphocarbolate 60 grains 

Alcohol 1 ounce 

Distilled water 2 ounces 

Oil of wintergreen 8 minims 

The patient should use the gum massage and gum 
wash at least three times a day. 

But let it be again emphasized: The importance 
of adequate dental assistance in the treatment of 
pyorrhea cannot be overestimated. 

FOUL BREATH 

It is* rarely excusable for a person having once discov- 
ered that the breath is offensive to neglect prevention of 
the odor. Perhaps the most frequent cause pertains 
to the teeth. There may be cavities, or there may 



262 TOOTH POWDERS AND DENTIFRICES 

simply be lack of cleanliness from an insufficient use 
of the tooth bru§h and the proper tooth powders, tooth 
pastes or mouth washes. It is also necessary to remove 
with a toothpick particles of food which may have 
become fixed between closely set teeth. All cavities 
should be filled and tartar deposits should be regularly 
removed, not only because of their likelihood to cause 
disagreeable odor to the breath, but of the possibility 
of allowing germs to develop and be swallowed. If 
the stomach is not in a healthy condition and the 
gastric juice not normal, such germs may not be killed. 
The proper tooth powder should be determined by the 
ease with which the teeth are cleaned, some requiring 
more friction in the powder, and others requiring more 
soap. The choice of the powder and the frequency 
with which the teeth should be brushed is determined 
by the results. They must be kept clean, and the 
cleansing must be done at least twice a day — in the 
morning and at bedtime. 

TOOTH POWDERS AND OTHER DENTRIFICES 

Although there are numerous tooth powders and 
other dentrifices available on the market, and although 
individual and varied claims are made for each, it is 
doubtful that much in the way of antisepsis or bac- 
tericidal effect in the mouth can be proved for any of 
them. It must be remembered that the action is evan- 
escent and that the moment the use of the preparation 
is stopped the first breath or mouthful of food may 
bring in a host of new bacteria. However, such prep- 
arations have excellent mechanical cleansing effects 
and may well be utilized for the purpose. 

If there is any tendency to alveolitis, or if purulent 
alveolitis is present, then antiseptic, followed by alka- 
line, mouth washes should be frequently used until the 
condition is cured, but if it tends to recur, then such 
mouth washes should be used once a day, continuously. 
For a time weak peroxid of hydrogen solutions are 
beneficial, especially if the acid, which is formed after 
its oxidizing action, is quickly washed away with an 
alkaline solution. If the gums are spongy a 5 per cent, 
solution of potassium chlorate makes an efficient mouth 



ATROPHIC RHINITIS 263 

wash. One of the best local astringents and local anti- 
septics is a dilute solution (perhaps one part to five) 
of alcohol in water. 

The teeth not being the cause of the odor of the 
breath, the tonsils should be examined, and not infre- 
quently little calcareous deposits will be found in one 
or more crypts, or there may be a pocket of caseous 
deposit back of the tonsil. These should, of course, be 
removed and the crypts treated with some antiseptic 
solution and a cleansing antiseptic gargle given. 

Another frequent cause of bad breath is postnasal or 
nasopharyngeal infection. If this is a chronic condition 
the treatment is tedious, and unless the patient thor- 
oughly cooperates, results will be unsatisfactory. The 
proper treatment of nasal and nasopharyngeal infection 
can only be determined by a study of the individual 
condition. A warm cleansing solution is, of course, 
always important, and the frequency of its use can only 
be determined by the rapidity with which the secretion 
forms deposits. 

In atrophic rhinitis the odor is terrible, and, unfor- 
tunately, the condition is generally incurable; but 
there is absolutely no excuse for such a patient pol- 
luting the atmosphere of the rooms in which he works 
or lives. The odor can be prevented by the proper use 
of mild antiseptic and cleansing solutions, such as 
Dobell's solution. This solution is as follows : 



B Phenolis 

Sodii bicarbonatis 

Sodii boratis 

Glycerini 

Aquae ad 

M. Sig. : Use as an antiseptic gargle or as a nasal anti- 
septic spray. 

Other causes of disagreeable breath are constipation 
and dyspepsia. The cause of these conditions should 
be treated, and as the tongue becomes clean and the 
pharynx less congested the breath will become better. 

Laryngeal and bronchial inflammations and catarrhs, 
of course, are other causes of bad breath. If the condi- 
tion is acute or subacute, it can soon be improved by 



Gm. 


or C.c. 


1 

3 
3 

10 
200 


m. xv 

or aa gr. xlv 

A3 iiss 

ad fl5 vii 



264 MOUTH WASHES AND GARGLES 






proper treatment. If the condition is a chronic one, 
mild antiseptic inhalations will largely prevent the 
fetid condition. 

Gm. or C.c. 

Ifc Creosoti 1 1 m. xviii 

Olei pini silvestris 101 or A3 iii 

Tincturae benzoini q. s. ad 100] ad AS iv 

M. Sig. : To inhale a teaspoonful from boiling water, one, 
two, or three times a day. 

MOUTH-WASHES AND GARGLES 

There are perhaps fifty mouth washes on the market. 
They are all more or less similar in their composition, 
more or less multiple in their constituency, and more or 
less expensive, and represent more or less enormous 
profits to their owners. A number of pharmacopeial 
and National Formulary preparations have been devel- 
oped to meet the need of mouth washes and also to 
imitate some of the proprietary preparations. 

Such polypharmacy as this is absolute nonsense. As 
in many pharmaceutical preparations, the value of the 
really useful ingredients is obscured by the useless 
camouflage which surrounds them. 

As antiseptic for the mouth and throat we cannot 
improve on the carefully localized applications of the 
tincture of iodin or of weaker solutions of iodin ; when 
deemed advisable, of a strong solution of nitrate of 
silver carefully applied locally; or of local swabbing 
with strong hydrogen peroxid solution, or the more 
generalized washing or spraying with dilute solutions 
(provided that hydrogen peroxid is not applied to a 
deep ulcer or sinus where it can possibly cause disin- 
tegration of tissue). Strong preparations of glycerin 
and strong solutions of alcohol are other pleasant anti- 
septics, and the latter is decidedly astringent. 

When a strong antiseptic is used, after it has acted 
for a few minutes, soothing washes or sprays should be 
used. Also it should be remembered that any simple 
cleansing wash (than which perhaps nothing is better 
than simple salt solution in so-called physiologic 
strength, 0.9 per cent., or *4 teaspoonful of salt to 
about half a glass of warm water to which may or may 
not be added another % teaspoonful of sodium bicar- 
bonate) is of value on an inflamed mucous membrane. 
After such cleansing of the membrane, the antiseptic 



FORMULA FOR MOUTH WASH 265 

may be directly applied, if such is indicated, or the 
cleansing and soothing gargle or mouth- wash just men- 
tioned may be all that is needed. It is not the par- 
ticular preparation that is used, or the particular 
ingredients in the mouth-washes and gargles, but it is 
efficient washing and gargling that is of benefit. 

The value of boric acid, not only in being mildly 
antiseptic, but also in promoting mucous secretion and 
therefore causing the easy removal of follicular exu- 
dates and membrane, should not be forgotten. Many 
times the insufflation of boric acid powder directly on 
the region involved is most efficient. At other times 
gargling of a solution in which boric acid is suspended 
is of value. While boric acid will dissolve in water 
only to about 4 per cent., a large surplus of boric acid 
should be left undissolved in the bottle. The bottle 
should be shaken, and the patient then gargles a boric 
acid solution which will deposit boric acid crystals on 
the throat, and will often be of as much value as 
though the powder were insufflated. 

Perhaps the most pleasing pungent taste to the 
majority of patients is peppermint, and there is no 
reason for mixing this up with several other aro- 
matics. If peppermint is disagreeable to a particular 
person, wintergreen may be substituted. 

The following are formulas of a few simple solu- 
tions for mouth and throat washes : 

Gm. or C.c. 

R Acidi borici 2 3 ss 

Potassii chloratis 5 or 3 i 

Aquae menthae piperitae.. . 200 flSvi 

M. Sig. : Use as a gargle or mouth-wash, diluted or undi- 
luted, as directed. 

Gm. or C.c. 

Ifc Sodii chloridi 

Sodii boratis aa 2 

Glycerini 50 

Aquae gaultheriae. . .q. s. ad. 200 
M. Sig. : Use as a gargle or mouth-wash, diluted or undi- 
luted, as directed. 

Gm. or C.c. 

~fy Acidi salicylici 2 

Glycerini 25 

Aquae menthae piperitae 

q. s. ad 200 flSvi 

M. Sig. : Use as a gargle or mouth-wash, diluted or undi- 
luted, as directed. 



3ss 

or AS iss 
flSvi 



gr. xxv 

fl3v 



266 USE OF GARGLES 

The value of dilute alcohol washes, such as one part 
of alcohol to four or five parts of water, should not 
be forgotten. Alcohol is astringent, cleansing and 
antiseptic. Sometimes potassium chlorate solutions, 
though very disagreeable, are most healing when the 
whole mucous membrane of the mouth is more or 
less inflamed. If there are no pockets in which hydro- 
gen peroxid may form bubbles and cause an exten- 
sion of ulceration, there is no mouth- wash more 
antiseptic and more efficient than diluted hydrogen 
peroxid solution, and one part of hydrogen peroxid 
solution to three or four parts of warm water. Imme- 
diately after the use of hydrogen peroxid solutions 
a mild alkaline solution should be used to wash off the 
froth caused by the peroxid action and also to remove 
the acid irritation caused by such action. 

If the mouth is dry during illness, some slightly 
pungent substance may be taken, to be either chewed 
or swallowed, such as some effervescing water, ginger 
ale, some pungent mint chewing-gum, or even a simple 
peppermint lozenge. Of course the value, in such 
conditions, of vegetable sours such as lemonade, 
orangeade or a piece of orange is well understood. 
These will increase the mouth secretions and prevent 
drying of the mucous membrane, which is such a 
frequent cause of ulceration. 

Various preparations of glycerin diluted with water, 
with or without boric acid or borax, or boroglycerid, 
or milk of magnesia, are all valuable in preventing or 
aiding in the healing of a sore mouth. 

If the tincture of iodin does not heal an ulcer or 
fissure, one or two applications of either the stick 
nitrate of silver or a 25 per cent, solution, applied by 
means of a swab, will generally cause healing. 

If the patient is too ill for strenuous or perfect 
cleanliness of the mouth, as soon as convalescence is 
established extra care should be given the mouth and 
teeth. 

It should not be considered that a patient has been 
thoroughly examined until the condition of the mouth 
has been investigated. As before stated, too many 
chronic diseases have their source and continuation 
from diseases of the gums or from neglected, decayed 
teeth, to say nothing of diseased tonsils. A fetid, bad 



CARE OF THE TEETH 267 

breath should always be investigated, as it is generally 
due to chronic inflammation in the mouth. While a 
large portion of adults over 40 have more or less 
pyorrhea alveolaris, a large number of these patients 
may have the conditions entirely prevented, and by 
various methods to-day many patients are cured of 
what was long considered an incurable condition. 

The foregoing of course are only suggestions, and 
each physician should order the mouth-wash that he 
desires for his patient as carefully as he would write 
any other prescription. There is nothing wonderful 
or mysteriously curative in any of the formulas 
described, and simple home remedies will often be as 
effective as an expensive proprietary preparation, 
unless an antiseptic is required. Even simple starch 
water makes a very soothing gargle. 

CARE OF THE TEETH 

It has too long been believed that a serious illness 
caused of itself degeneration of the teeth, either cavi- 
tation or actual loss. While there are many of the 
elements of nutrition that are needed for the teeth to 
remain healthy, neglect of the mouth and teeth is 
probably the larger factor in their degeneration. 
Tartar forms, inflammation begins and pus-pockets 
develop around the teeth when they are not properly 
cleansed and the gums are not properly cared for. 

If the patient is so ill that he cannot allow brushing 
of the teeth either by himself or by the nurse, the 
gums and teeth should be cleansed by rubbing or 
spraying with the liquids selected. A great source of 
cleanliness for the teeth is chewing, which is more or 
less in abeyance during serious sickness, but we are 
learning that in most of the prolonged acute diseases 
the patient is able and willing to chew such a simple 
thing as dry toast. This alone cleanses the teeth, 
starts the saliva, and normal mucous flow, and fre- 
quently offers a better food than the constant swallow- 
ing of even nutritious liquids. If the ordinary simple 
cleansing lotions are not sufficient to prevent the forma- 
tion of pus or ulcerations, various applications to the 
regions of trouble should be made, and perhaps none 



268 EXAMINATION OF STOMACH CONTENTS 

is better than the tincture of iodin, or, if that is con- 
sidered too severe, a modified solution of iodin as 
follows : 

Gm. or C.c. 

IJ Iodi II gr. xv 

Potassii iodidi 3\ or gr. xlv 

Glycerini 30 1 AS i 

M. Sig. : Use externally as directed. 

Gies found that so-called antiseptic mouth-washes 
and alkaline washes did not wash off or dissolve the 
adherent mucin, and therefore are not effective in pre- 
venting decay of the teeth. He believes that the vege- 
table acids, such as diluted vinegar and the fruit juices 
and their acids, are the most successful cleansing sub- 
stances that can be used on the teeth. He also 
believes that starches and sugars should never be 
eaten alone, but should be certainly followed by some 
acid' substance, as some of the acid fruits or some of 
the vegetable sours. After most meals, therefore, it 
is good sense to eat a little fruit, and on going to bed 
perhaps the most successful cleanser of the teeth is 
a little sour fruit or diluted fruit vinegar. 

Children and patients should also be taught to brush 
the gums as well as the teeth, and when it is needed a 
patient should be taught to massage the gums. The 
use of wooden toothpicks to remove particles between 
the teeth that cannot be removed by the toothbrush 
should be approved. 

Many patients' teeth are so close together that par- 
ticles of food remain lodged between them and cannot 
be removed in any other way. Dental floss should 
certainly be used occasionally, or frequently, if pos- 
sible. If inflammation actually occurs in the gums or 
around a tooth, the advice and care of a dentist are 
needed. 

THE EXAMINATION OF STOMACH CONTENTS 

Test Meal. — The object of the test meal is to show 
the state of digestion. For this purpose a meal con- 
sisting of ordinary food is most appropriate. It has 
recently been suggested that gastric secretion is suf- 
ficiently stimulated by ordinary water and in this way 
the gastric juice can be secured in a state of great 
purity, especially fit for chemical examination. While 



EXAMINATION OF STOMACH CONTENTS 269 

this is true such a meal does not indicate how the 
stomach deals with ordinary food. For the latter 
purpose the test breakfast of Ewald has long been 
used and has proved itself very serviceable. It should 
be used as a routine. It consists of bread and tea or 
bread and water. The amount of bread should be 
from 35 to 50 gm. No butter, sugar, milk or spices 
are used. The amount of bread can be supplied by 
two slices of bread, a roll, or five ordinary soda crack- 
ers. The amount of tea should be two ordinary cups 
approximating 400 c.c. or a pint. 

The meal should be taken on an empty stomach, 
before breakfast or in place of the noon meal. The 
latter time has the advantage that in case of motor 
insufficiency remains of the breakfast may be found 
in the stomach contents. In this case it is well for 
the patient to eat some article of food for breakfast 
that can be easily recognized. The test meal should 
be tastefully prepared and tastefully served. Such 
table accessories should be furnished as will make 
it as attractive as possible. Preparations for the 
removal of the contents should be made without 
attracting the attention of the patient. The time for 
removing the contents should be reckoned at one hour 
from the time of beginning the meal. 

In some cases this time may prove too long because 
the lack of acid permits the contents to leave the 
stomach prematurely and no contents are brought back 
through the tube. In such a case the meal should be 
given again and the contents removed at the end of 
forty-five minutes or even a half hour. 

Removal of Stomach Contents. — The technic of 
removing stomach contents is simple. The patient 
should be covered with an apron to protect the clothing ; 
the physician may also find it advantageous to wear a 
gown. A shallow basin should be provided to receive 
the contents; a better arrangement is a stout glass 
jar known as a celery jar which should be placed 
in a larger basin. It is well to suggest to the patient 
to hold the basin with his hands. This serves to keep 
the hands occupied and tends to lessen the tendency 
of the patient to pull out the tube. The patient should 
be assured that the operation will not hurt; at the 
same time it is best to admit that it will be disagree- 



270 EXAMINATION OF STOMACH CONTENTS 

able and especially that it is apt to give a sensation of 
difficulty in breathing, but that this will disappear if 
the patient breathes regularly through the nose. The 
tube to be used is a simple tube with one lateral 
opening and one at the end. To the upper end a short 
piece of rubber tubing is attached by a. connecting 
short piece of glass tubing and the shorter tubing is 
attached by a piece of hard rubber to a strong walled 
bag like a Pollitzer bag. This serves as an aspirator 
to remove the contents by suction. 

The tube is introduced by the hand of the operator 
holding it like a pen. It is not necessary for the hand 
to enter the mouth. The operator should stand partly 
behind the patient and may steady the patient's head 
with the left hand. When the tube has entered the 
stomach the contents may flow spontaneously; if not 
the flow may be stimulated by moving the tube up 
and down which excites some nausea. If the contents 
are not easily obtained the aspirator should be emptied 
of air and attached. When it is allowed to expand 
the contents will flow into the bag and can be emptied 
into the receptacle provided. The temptation will 
sometimes arise to facilitate the removal of contents 
by injecting water. This defeats the object of the 
removal as the contents obtained are practically worth- 
less even for qualitative tests. At the termination of 
the process the patient should be warned against 
spitting in the dish containing the contents. He may 
spit in the outer basin. 

Examination. — The stomach contents should be 
measured. The contents ordinarily secured varies 
from fifty to one hundred and fifty cubic centimeters ; 
a quantity above 150 c.c. is indicative of one of two 
things : either there has been a retention of food rem- 
nants on account of motor insufficiency or a hyper- 
secretion of the gastric juice has occurred. The chemi- 
cal examination will usually determine this question. 

The macroscopic examination of stomach contents 
is perhaps of more importance than the laboratory 
investigation. For this reason the physician should 
remove the contents himself. The contents should 
be poured into a clean basin and poured back again 
into the original dish. The color should be noted. A 
greenish color may indicate admixture with bile; it is 



EXAMINATION OF STOMACH CONTENTS 271 

also sometimes due to a growth of mold or other 
fungi. Mucus will be recognized by the stringiness 
of the contents which is readily seen as the liquid is 
poured from one vessel into the other. Mucus may be 
swallowed from the throat or possibly from the chest. 
Such mucus is light and frothy, or in lumps which 
float on the surface; stomach mucus clings to the 
vessel and is intimately mixed with other contents. 
Blood may be readily recognized, but is of minor sig- 
nificance; it is frequently shed by the mucosa which 
has been injured by the tube. The mucosa is espe- 
cially liable to suffer such an injury in achylia gastrica. 
The condition of digestion is easily observed by the 
appearance of the remnants of the roll. If digestion 
is good the gluten of the flour is digested and the 
starch sinks to the bottom as a fine sediment. If the 
digestion is imperfect the roll is coherent and in case 
of total lack of acid the bread appears as if it had just 
been swallowed or it may be enveloped in glairy mucus. 
Occasionally small pieces of mucous membrane will be 
found which have been stripped off by the tube. 

Having noted these striking characters one should 
proceed to the chemical examination. Usually it is 
not necessary to filter the contents. A piece of congo 
paper may be dipped into the contents ; if free acid is 
present the red paper changes to blue. A piece of 
tropeolin paper will turn brown if free hydrochloric 
acid is present and on drying this at a gentle heat the 
color will change to violet. This is usually sufficient 
to demonstrate the digestive power of the mixture. 
One proceeds at once to the titration of acids for which 
a determination of the free hydrochloric acid and the 
total acidity are sufficient for routine examinations. 
10 c.c. of the contents are measured, most conveniently 
in a 10 c.c. graduated cylinder and poured into a small 
beaker glass. It is well before reading the amount 
in the cylinder to remove any mucus floating on the 
top by means of a pair of small forceps and fill up to 
the mark with clear fluid. After emptying the cylinder 
it may be rinsed with distilled water and the rinsings 
added to the fluid in the beaker. This .is then titrated 
for free HC1 by running in from a burette decinormal 
sodium hydroxid solution with dimethyl-amino-azoben- 



272 EXAMINATION OF STOMACH CONTENTS 

zene as an indicator until the red liquid becomes 
orange yellow (not lemon yellow). The reading of 
the burette is then taken and one or two drops of 
solution of phenolphthalein are added to the liquid in 
the beaker. The alkali solution is then run in until 
the liquid shows a distinct tinge of pink after stirring. 
This gives the total acidity; both readings are taken 
from the zero point and the figures multiplied by ten 
to get the amount of alkali required to neutralize acid 
in 100 c.c. of stomach contents. These figures are 
customarily used in reports and are designated as the 
degree of free and total acidity. 

The tests described above consume little time (not 
more than fifteen minutes for one accustomed to the 
work) and may suffice for the examination in the 
majority of cases. Some other tests ordinarily de- 
scribed, are not needed in ordinary clinical work 
because their results can be predicted from the results 
of tests already made. Among these may be included 
the following. Tests for the digestive action of the 
saliva are unnecessary because we may assume with 
fair certainty that starch digestion will be poor in the 
presence of high acidity, fair with normal acidity, and 
very good with low acidity. Tests for the presence 
of pepsin are unnecessary unless there is no free 
hydrochloric acid. In the absence of hydrochloric acid 
the presence and amount of pepsin should be tested 
for. Tests for lactic acid are quite unnecessary when 
there is free hydrochloric acid. When hydrochloric 
acid is very deficient or absent lactic acid should be 
tested for. Kelling's test for lactic acid may be 
used : Add a few drops of 5 per cent. Fe Cl 3 solution 
to a test tube of distilled water sufficient to produce a 
faint yellow color. Divide this info two parts. Keep 
one for comparison. To the other add a few drops 
of the gastric juice. A distinct canary yellow color 
appears if lactic acid is present. If the total acidity 
is as low as 8 the probability of achylia gastrica may 
be assumed. 

Microscopic Examination. — For examination with 
the microscope a drop of the contents is placed on a 
slide and examined with a low power. It can advan- 



EXAMINATION OF FECES 273 

tageously be stained with a weak Lugol's solution. 
Starch is colored blue, proteins yellow, and some bac- 
teria blue. The objects of interest are Oppler-Boas 
bacilli, long bacilli often bent on themselves, sarcinae 
masses of cocci aggregated in groups of eight with 
divisions between the individual cocci which cause the 
mass to look like a fleece of wool, yeast cells and starch 
granules. 

EXAMINATION OF FECES 

The examination of feces is of little value so far as 
the diagnosis of indigestion is concerned unless a 
definite diet is prescribed so that one may know what 
appearances the residues of the food should present 
under normal conditions. The original test diet of 
Schmidt was devised so as to conform to German 
dietetic customs and is ill adapted to American habits. 
Several modifications of this diet have been proposed, 
among them the following menu by Dr. M. M. Scar- 
borough. 

Breakfast: — One soft boiled egg, 2 slices of toast 
with butter, 1 bowl of oatmeal with sugar and cream, 
1 glass of milk, and 1 cup of coffee. If coffee is not 
desired, another glass of milk may be substituted. 

Dinner: — A quarter pound of finely chopped round 
steak (very slightly broiled so that most of it is rare), 
y 2 pound of mashed potato, 2 slices of white bread or 
toast, plenty of butter, and 1 or 2 glasses of milk. 

Supper: — Same as the breakfast. 

A patient is put rigidly on the above diet for three 
or four days. At the beginning of the diet he is given 
a tablet or capsule containing 0.30 gram (5 grains) of 
pure willow charcoal. This dose of charcoal is 
repeated at the end of the diet. The consequent black 
stools from these two doses of charcoal will mark the 
beginning and end of the period of special diet. The 
length of time it takes the charcoal to go through the 
intestines will determine their activity and whether 
the food is delayed or not in its passage through the 
alimentary tract. The second dose of charcoal is use- 
ful only to determine whether the activity of the canal 
has changed during the rigid diet. The stool which 
is to be taken for examination should be at the end of 



274 EXAMINATION OF FECES 

the third 24-hour period of the diet and before the 
administration of the second dose of charcoal. The 
stool desired may be collected in a wide mouthed jar 
or what is more convenient for the ordinary examina- 
tion, a sample may be transferred to a glass ointment 
jar and transmitted to the laboratory for examination. 
The examination may be divided into macroscopic, 
microscopic and chemical. 

Macroscopic Examination. — Macroscopically, under 
normal conditions, we find a soft-formed stool, light- 
brown in color and of uniform consistency. A liquid 
stool usually denotes a too rapid passage of food 
through the tract ; a tarry stool indicates blood coming 
from the stomach or high up in the intestine. Flakes 
of mucus, blood, pus, etc., are pathologic. Next a piece 
of feces the size of a walnut is ground up in a mortar 
with a little water and then spread out on a glass plate 
in a thin layer. The plate should be placed over a 
sheet of paper half of which is white and half black. 
The normal feces appear perfectly homogeneous except 
for here and there small broken, brownish points 
of cellulose from the oatmeal eaten. In this prepara- 
tion may be seen food remains which are abnormal. 
Firm, whitish or yellowish strings of connective tissue, 
and small brown-colored rods of muscle fibre, appear- 
ing like splinters of wood, may be seen here and there, 
denoting improper indigestion of the meats. Starch 
granules in the form of glassy transparent globules 
like sago grains, may be present and must be distin- 
guished from shiny, ragged flakes of mucus. 

Microscopic Examination. — The microscopic exam- 
ination is very simple. A small mass of feces is 
pressed out in a thin layer on a slide by means of a 
cover glass. A little water may be added if necessary. 
Normal excrement from the test-diet appears as a fine 
detritus of granules, globules and bacteria interspersed 
here and there with fragments of muscle fibers, small, 
irregular, yellowish flakes of calcium salts and less 
numerous skeletal remains of potato cells, besides the 
chaffy particles from. the oatmeal. On a second slide 
a small piece of feces is stirred up with two drops of 
a 35 per cent, solution of acetic acid, heated over a 
flame until bubbles arise, and then set to cool. The 



EXAMINATION OF FECES 275 

process causes a liberation of the free fatty acids which 
flock out on the surface of the preparation, giving a 
rough index to the amount of fat in the stool. 

On a third slide an igdin solution (liquor iodi com- 
positus, Lugol's solution), diluted with equal part of 
water, is used, which stains the starch, yeast and 
other fungi that may be present. The microscopic 
examination may reveal the following pathologic com- 
ponents: fragments of muscle fibres large in size and 
in good state of preservation; clusters of undigested 
starch grains; numerous needles and crystals of fatty 
acids and soaps; and occasionally various fungi. 

Chemical Examination. — The chemical tests are very 
simple. The litmus reaction is taken; normal stools 
are faintly alkaline or at least feebly acid. Next a 
little of the stool is mixed with a strong bichlorid 
solution (a saturated solution of corrosive sublimate 
in water, which is, in cold water, not far from 7 per 
cent.) ; normal feces give a red reaction, while feces 
that have passed through the tract so rapidly that the 
bile has not been reduced to give a greenish color. The 
greenish color is abnormal and shows that unchanged 
bile pigments have passed entirely through the intes- 
tinal tract. The last test is the amount of gas that 
the stool will give off. An acid stool with an excess 
of carbohydrates will ferment if kept warm and give 
off considerable carbon dioxid; on the other hand 
a stool which gives an alkaline reaction and contains 
much unabsorbed protein will readily undergo putre- 
faction and evolve ammonia and hydrogen sulphid. 
The gas from decomposing feces can be collected by 
filling a large test tube with diluted feces and invert- 
ing the tube over water in a shallow dish and placing 
in an incubator for a day or two. 

Pathologic Findings. — The significance of pathologic 
findings are briefly as follows : 

Mucus in the stool means inflammation of the colon 
or rectum. Rarely it may come from the small intes- 
tine. A green color with the bichlorid test indicates 
a very rapid passage of intestinal contents. Absence 
of bile pigment denotes complete obstruction of the 
biliary duct. The pigment may be obscured by excess 



276 EXAMINATION OF FECES 

of fat, which should be removed by ether before a 
final opinion as to the absence of biliary pigments 
should be expressed. 

The finding of meat remains«is of great significance. 
Connective tissue never appears in the feces after the 
test-diet unless there is disturbance of digestion in 
the stomach, a diminished gastric juice. Muscle fibers 
are not digested in the stomach, but in the intestine. 
Even in complete achylia gastrica the muscle fibers 
may be completely digested leaving the connective 
tissue skeleton of the meat unaffected. The presence 
of muscle fibers in a good state of preservation always 
means trouble in the small intestine, due to one or 
more of the following conditions : the pancreatic juice 
may be insufficient; or the active enterokinase of the 
secretions of the small intestine may be absent; or 
finally, there may be a marked hypermotility, too rapid 
peristalsis, of the small intestine, thus not allowing 
time for digestion of these elements. A method for 
the investigation of the exact cause of intestinal indi- 
gestion of meat fibers has not yet been satisfactorily 
worked out. However, as the nuclei of tissue cells are 
digested only by the pancreatic secretion, Schmidt has 
devised his nuclei test which consists in giving a small 
cube of meat placed in a small porous silk bag. The 
bag almost always contains remains of the tissue after 
passing through the gastro-intestinal tract. If undi- 
gested nuclei are present, it is safe to conclude that 
there is an unsatisfactory functioning of the pancreas. 

The presence of starch elements indicates its incom- 
plete digestion in the small intestine and shows a dis- 
turbance of the pancreatic secretion and of the intes- 
tinal juice. Insufficiency of starch digestion is further 
confirmed by the fermentation test and by the finding 
in the stool of organisms that stain blue or violet with 
iodin. 

In the feces of constipated persons, as a rule, there 
are few food remnants, few bacteria, and water has 
been largely absorbed rendering the feces dry and hard. 
Digestion in the constipated may be said to be too 
good. 



EXAMINATION OF FECES 277 

DIAGNOSIS AND TREATMENT 

The diagnostic findings and the indications for treat- 
ment may be summed up as follows : 

1. If the charcoal is slow in passing through the 
alimentary canal, i. e., more than thirty-six hours after 
ingestion, intestinal peristalsis is sluggish. 
. 2. If the fecal matters are very dry, there is too 
great absorption of liquid from the intestines. 

3. If the stools are very liquid, there is generally 
too rapid peristalsis. 

4. If the fecal matters are distinctly or very acid, 
there is an imperfect intestinal digestion. 

5. If there is much gas in the feces, there is maldi- 
gestion of some kind; it may be purin maldigestion 
or carbohydrate maldigestion. Whichever it is deter- 
mined to be, that particular kind of food should be 
limited. 

6. If there is undigested connective tissue found 
microscopically, the trouble lies in the stomach, which 
should then be studied by means of the test breakfast 
and examination of the stomach contents withdrawn 
an hour after the test breakfast has been taken. If 
there are undigested muscle fibers present, there is 
insufficient pancreatic secretion, and meat should be 
diminished or temporarily withdrawn from the diet. 

7. If there is a large amount of undigested starch 
particles, the pancreatic juice is deficient, at least in its 
starch digestion properties ; consequently the starch in 
the diet should be diminished. 

8. If the bile pigments are absent,, of course the bile 
is not secreted (or excreted) into the alimentary tract. 
If there is a large amount of fatty acids, or if there 
is a large amount of fat in the stool, it shows defi- 
cient bile secretion, and the amount of fat ingested 
should be greatly diminished. 

9. Abnormal bacteria, or an abnormal amount of 
bacteria, or specific bacteria would suggest various 
diets, bowel antiseptics, purgings, and various sys- 
temic treatments, depending on the findings. 



278 INTERPRETATION OF STOMACH SYMPTOMS 

10. Much mucus or pus would suggest the treat- 
ment, depending on the region from which it was sup- 
posed to come; colon washings or colon treatments, 
if the colon was at fault. 

11. If there is blood in the stool, evident or occult, 
it must be determined, if possible, from what part of 
the tract it comes. 

THE FINDING OF PATHOLOGIC OVA 

Fauntleroy and Hayden (Abstr. Jour. A. M. A., 
Feb. 13, 1915, p. 620) have devised a method which 
consists essentially of staining the fecal matter with 
anilin gentian violet. This solution stains everything 
on the slide except the eggs. It does not pene- 
trate the membrane about the eggs and they are 
therefore left in a natural state. None of the other 
ordinary colored stains will do this. The entire slide 
with the exception of the real eggs is stained violet. 
This method of examination has been used in the exam- 
ination of over a thousand stools with uniform success. 
All eggs, hookworm and others, stand out very clearly 
and beautifully. About 2 gm. of the fecal material 
are thoroughly mixed with 5 c.c. of a 2 per cent, aque- 
ous solution of compound solution of cresol in a cen- 
trifuge tube. The specimens are centrifugalized at 
high speed for one minute, the supernatant liquid is 
then decanted and fresh compound cresol solution 
added and mixed with the sediment in the tubes. This 
operation is repeated three times. On completion of 
the centrifugalization process a small portion of the 
bottom sediment is removed with a clean pipette and 
placed on a clean slide, a small drop of anilin gentian 
violet mixed with the sediment, and a clean cover- 
glass placed on it. See also description of methods 
under "Hookworm." 

INTERPRETATION OF SYMPTOMS REFERABLE 
TO THE STOMACH 

There is perhaps no group of symptoms regarding 
which there is more misapprehension among physi- 
cians than symptoms arising from the stomach or felt 
in the region of the stomach. 



INTERPRETATION OF STOMACH SYMPTOMS 279 

INDIGESTION 

Indigestion is a much abused term commonly used 
to cover all forms of stomach disease. Strictly it 
means the non-digestion of food. This is a rare event 
among those who are not seriously ill. That digestion 
may fail in the stomach or in some other part of the 
alimentary canal or that some parts of the food may 
escape digestion is common enough, but the human 
organism is provided with compensating mechanisms 
so that if one organ in the digestive system fails to 
perform its duty another is usually capable of taking 
its place. As a rule in adults, even in the case of 
those who complain of trouble with the stomach or 
bowels, only a minimum of the food ingested escapes 
digestion or fails to be absorbed. The test of diges- 
tion is found in the state of the bowels ; if the bowels 
act normally or are constipated as a rule the digestion 
is complete and may indeed be too good. If there is 
diarrhea it may be assumed that digestion is imperfect, 
although there may be no lesion of the stomach or 
intestines. We may repeat that indigestion is not a 
common symptom in the ordinary chronic affections 
of the stomach and intestines. As a corollary of the 
above we may affirm that digestive ferments are not 
often lacking and there is rarely a rational indication 
for prescribing artificial ferments to supply a lack 
in the normal action of these organs. Such drugs 
should be prescribed only after their deficiency has 
been shown by the proper tests. 

THE IMPORTANCE OF STOMACH DIGESTION 

It is not desirable to over-rate the importance of 
the processes going on in the stomach in the final 
process of digestion. The stomach is a preparatory 
digestive organ. It is a reservoir which reduces the 
food to a fine state of subdivision and renders it suit- 
able for the subsequent action of the secretions of 
the liver, pancreas, and intestines. Its work is seldom 
complete. The organ may be removed or fail to 
perform its functions without any serious disturbance 
in nutrition. Nevertheless one cannot deny that 
changes in the utilization of food may occur in the 



280 INTERPRETATION OF STOMACH SYMPTOMS 

absence of the correct functions of the stomach which, 
in the long run, may seriously affect metabolism and 
nutrition. In this connection we may note some 
peculiarities of the motor action of the stomach which 
have important bearings on treatment. The stomach 
does not absorb water and hence in case a liquid 
which needs no digestion is taken, even at meal time, 
a special channel is formed along the lesser curvature 
by which the liquid is conveyed to the intestine with- 
out mingling with more solid undigested contents 
of the stomach. The taking of liquids at meal time 
does not, therefore, dilute the gastric juice as was 
formerly taught. Such an event may happen, how- 
ever, when the stomach is atonic and allows water 
or other liquid to flow into the lower part instead 
of conducting it into the intestine in a normal manner. 

RELATION OF THE STOMACH TO OTHER ORGANS 

It should always be borne in mind that the stomach 
has important nervous connections with other organs 
by which it reflects like a mirror events taking place 
in other parts of the digestive system. Symptoms 
apparently arising in the stomach may, in reality, 
depend on disease of the liver, gall-bladder, appendix, 
or lower bowel. Neighboring organs not connected 
with the process of digestion or even remote organs 
may produce a reflex disturbance in the stomach. A 
very large part of the disturbances of the stomach 
is of psychic origin. The physician should always 
interpret the symptoms presented by the patient who 
thinks there is something wrong with his stomach in 
the light of possible disease of other organs or of 
mental disturbances. Even in the presence of proved 
organic disease the possible influence of emotion in 
producing symptoms should not be forgotten. 

THE MAJORITY OF STOMACH CASES FUNCTIONAL 

While the existence of serious organic disease 
should never be overlooked it is well to understand 
that only a small proportion of patients who come 
to the physician complaining of the stomach or of 
digestive disturbances have ulcer or cancer. The 



INTERPRETATION OF STOMACH SYMPTOMS 281 

physician should not make or suggest a diagnosis of 
serious disease until he has proved its existence by 
appropriate physical and laboratory examinations. 

SYMPTOMS NOT CHARACTERISTIC 

Diagnosis on the basis of the patient's recital of 
symptoms without physical examination or the anal- 
ysis of a test-meal or of the feces is much too com- 
mon. It may be said at the outset that there 
exists scarcely a symptom that is characteristic of any 
definite stomach disease. This may explain the readi- 
ness with which practitioners resort to such terms as 
indigestion, dyspepsia, catarrh of the stomach or the 
indefinite term "stomach trouble" to explain their 
diagnosis to the public. 

THE RARITY OF FERMENTATION IN THE STOMACH 

Formerly it was a favorite custom to explain the 
belching of gas from the stomach and the flatulent 
distention of the organ, as also the "sour" stomach, 
by saying that these symptoms arose from the fer- 
mentation of the food. Such an explanation gave rise 
to attempts to suppress fermentation by giving a host 
of antiseptics, some of powerful and some of feeble 
germicidal power. This explanation and the practice 
based on it arose from the application of a chemical 
theory without sufficient regard for the actual condi- 
tions prevailing in the stomach. The contents of the 
stomach are at times subject to fermentation with the 
production of a certain amount of gas. Lactic acid 
may be formed by fermentation, but usually no gas is 
formed with it ; butyric acid may occur in the stomach 
contents and its formation is accompanied by the 
evolution of some gas ; yeast fermentation forms gas 
at times. However, if one will watch one of these 
fermenting liquids he will find that ordinarily the 
formation of gas is slow and quite insufficient to 
account for the belching that many patients experi- 
ence. These occasional sources of gas account for its 
accumulation only in rare cases. In the majority of 
cases the gas present in the stomach consists of 
swallowed air. As a rule, even in cases in which much 
distress is produced by flatulence or belching, there 



282 ACUTE DYSENTERY 

is no fermentation in the stomach. The swallowing 
of air may be a habit of voluntary origin or it may 
arise from the forcing of air through an atonic cardiac 
orifice by the force of expiration. The acid present 
in the stomach contents is seldom the result of fer- 
mentation but is produced by oversecretion of the 
gastric juice. It is well, therefore, to ascertain the 
true origin of these symptoms before attempting to 
prevent them by the administration of injurious anti- 
septics. 

ACUTE DYSENTERY 

Acute dysentery or colitis is an inflammation of the 
large intestine, throughout either the whole or a por- 
tion of its extent. Sometimes the lower part of the 
small intestine is coincidently inflamed. The disease 
may be due to various irritants of microbic or parasitic 
origin, giving essentially similar symptoms but requir- 
ing different treatment addressed to the cause of the 
disease. As Mathieu remarks, we should not speak 
of dysentery but of "dysenteries," as there are several 
kinds of dysenteric colitis. It is, however, convenient 
to discuss the symptoms and general treatment in 
common for the different varieties and then take up 
the specific treatment of the different forms. 

The disease is characterized by mucus, blood and 
purulent discharges from the rectum, accompanied by 
much straining, colicky pains and tenesmus. The fol- 
lowing classes of dysentery may be noted: bacillary 
dysentery, amebic dysentery, balantidium dysentery, 
and dysentery arising from some unknown infection. 
The disease is, therefore, infectious, and may be trans- 
mitted by the discharges or articles contaminated with 
them. It occurs in epidemics and also sporadically. 
When dysentery occurs sporadically it is generally 
more amenable to treatment. 

SYMPTOMS 

The general symptoms of acute dysentery are mild 
fever, a variable pulse, at times rapid or weak from 
exhaustion, with a tendency to collapse turns; the 
movements are frequent and exhausting. The nearer 
the rectum the inflammation is, the more intense is the 
tenesmus and the more constant the desire to strain, 



TREATMENT OF DYSENTERY 283 

with resulting small movements and but little relief. 
The higher up the inflammation is in the large intes- 
tine, the more frequent the griping and abdominal 
pain. The stools consist of large masses of mucus 
mixed with feces, and later mucus, more or less blood- 
streaked, perhaps without any fecal matter at all. 
Later, slight hemorrhages occur, depending on the 
amount of ulceration or erosion of the membrane, and 
finally pieces of membrane are passed similar to diph- 
theritic membrane. The tongue is coated, but gener- 
ally moist, unless a large amount of fluid is lost. If 
the progress of the disease is unfavorable, the tem- 
perature is likely to rise high, otherwise it remains 
low. If the disease long continues and the movements 
are frequent and profuse, a typhoicl state develops. 

GENERAL PRINCIPLES OF TREATMENT 

It is evident that the first steps in the treatment 
are rest, the removal of irritants, and the giving of 
most easily assimilable nourishment. These principles 
apply to all forms of dysentery. The patient should 
be put to bed and the use of the bed pan insisted on. 
If the condition of the patient will permit the rectum 
should be inspected with a speculum or with a procto- 
scope and a piece of mucus or a scraping from an 
ulcer if any are visible obtained for examination. 
This should be examined immediately on a warm 
slide for amebae which are recognized by the ameboid 
movements. If no amebae are found the mucus and 
feces should be examined bacteriologically for other 
causes of dysentery. Following this examination the 
rectum and colon should be irrigated with physiologic 
saline solution. After the fecal matter and mucus have 
been washed away and the water is returned clear, the 
colon may be treated with a weak permanganate of 
potassium solution, 1 : 10,000. In making these irriga- 
tions the tube should not be pushed too far, which 
might increase the injury to the rectum. A few inches 
is sufficient. Such irrigations may be repeated once a 
day in the early stages. 

The Diet. — The diet should consist of rice water 
bouillon, beef juice, chopped beef, or other suitable 
liquid food. If the tongue is coated, the other foods 



284 MEDICINAL TREATMENT OF DYSENTERY 

mentioned agree better than milk, but if the tongue is 
clean give milk either alone or diluted with some of 
the other foods. The food must not be hot or cold. 
Milk predigested with pancreatin may obviate the 
tendency to the formation of an undue amount of 
intestinal gas. 

If milk is desirable but is distasteful, it may be 
diluted with Vichy; or the milk may be given hot 
and salted. Preferably it should be pasteurized. 
Tea and coffee may be allowed at such times of 
the day as not to disturb the sleep. While large 
amounts of water are inadvisable and iced water 
should not be given, still, if much water is lost by the 
stools, the amount *nust be equaled by that which is 
ingested; otherwise the patient's tissues lose water, 
the blood vessels lose water, the urine becomes con- 
centrated, the skin dry, and the patient suffers from 
this deprivation of water. Such a condition alone 
may be the cause of death. Preferably, liquids or 
foods should be given hot, as anything cold entering 
the stomach is likely to start peristalsis. It may be 
advisable to give some thin cereal gruel once a day, 
at least if the disease lasts more than a week. 

As soon as convalescence is established, broiled 
lamb chops, roast beef, and the white meat of chicken 
may be added to the diet. All solid food should be 
thoroughly masticated and the digestion may be 
hastened by giving a few drops of hydrochloric acid 
directly after meals. As convalescence progresses 
favorably, toast, stale bread, a'nd boiled rice may be 
added to the diet and, later, baked potatoes. The first 
fruit that is allowable is either lemon or orange juice. 

MEDICINAL TREATMENT 

It is generally advised to give at once a dose of 
castor oil or a dose of calomel with additional laxative 
treatment in the form of saline laxatives if necessary. 

Bismuth subcarbonate may be administered in large 
doses, but the value of this is often problematical. 
However, if the inflammation is in the cecum or has 
migrated into the ileum, the bismuth is of benefit. 



BACILLARY DYSENTERY 285 

Bismuth, however, must not be too long continued, as 
it tends to form scybalous masses and cause more irri- 
tation and more inflammation. 

Pain and too frequent movements should be stopped 
by small doses of morphin. Tenesmus is relieved by 
small ice water enemas or by suppositories of morphin 
and atropin. 

Kaolin or bolus alba has been recently revived as 
a remedy for dysentery. This treatment was in vogue 
more than a century ago but fell into disuse. It is 
claimed that the powder encloses the bacteria and 
prevents their pathogenic action. Probably this drug 
has an action in every way similar to that of bismuth 
in forming a protective coating to the mucous mem- 
brane. 

TREATMENT OF BACILLARY DYSENTERY 

The microscopic examination may show any one 
of a number of already classified dysentery organ- 
isms; for example, the Flexner, Shiga, and other 
types. Such examination should include fermentation 
tests and other biologic reactions as well as a studv 
or morphology. The classification, while a matter of 
great scientific interest, is not, however, an impor- 
tant guide for the prognosis or treatment. 

The general treatment already outlined is applicable 
to bacillary dysentery. Certain special measures also 
may be followed. 

Antidysenteric serum may be administered. A 
reduction in the mortality rate of bacillary dysentery 
from 30 to 50 per cent, through the use of some 
serums has been reported by some observers but not 
confirmed by all. Several forms of such serum are 
now available. It is customary to use 10 c.c. as a 
prophylactic dose. In the treatment 50 c.c. to 100 c.c. 
are given intravenously, a polyvalent serum being used. 
The dosage may be repeated later as the condition of 
the patient warrants. 

Nolf found the specific serums to have little virtue 
but achieved excellent results with vaccines made of 
Flexner and Shiga type bacilli. 

If the disease -progresses and immediate healing of 
the inflammation does not occur, and actual ulceration 
seems to have developed, as shown by the amount of 



286 AMEBIC DYSENTERY 

bleeding, an occasional irrigation of nitrate of silver, 1 
part to 1,000, not more than 1 pint at any one 
time, viz., 0.50 gram (7y 2 grains) to a pint of water, 
is of benefit. Such an injection should be given but 
once in four or five days, and if the liquid does not 
immediately flow out of the colon a solution of salt 
should be immediately injected. The salt forming an 
insoluble sodium chlorid, will prevent any poisonous 
absorption of nitrate of silver. 

TREATMENT OF AMEBIC DYSENTERY 

The diagnosis of amebic dysentery should always 
be confirmed by a competent study of the morphology 
of the organism isolated, as well as the injection of 
the organisms into the rectum of kittens. 

The general treatment of amebic dysentery is the 
same as that of bacillary dysentery. 

The specific treatment of amebic dysentery, which 
is comparatively recent, is with the aid of ipecac and 
emetin. 

Whether the amebae are on the surface of the 
mucous membrane, deeply embedded in the ulcers, or 
localized elsewhere in the body, they may be reached 
by properly administering ipecac and emetin. The 
amebae on the surface of the mucous membrane are 
not likely to be affected by emetin administered 
hypodermically. On the other hand, emetin given 
hypodermically becomes more quickly active on the 
deep seated organisms and the localized lesions. Jones 
reports the following method of administration is 
used at the Army hospital in Manila : 

Emetin hydrochlorid 0.008 gm. by hypodermic for 
ten days (twice a day for four days and once a day 
for six days). Ipecac started about the eighth day 
with from 1.5 to 2 gm. doses given at bedtime, con- 
tinued for three consecutive nights and thereafter 
decreased by 0.3 gm. each consecutive night. The 
disagreeable effects of the ipecacuanha were never 
manifested. It is quite necessary to precede the 
administration of ipecacuanha by a hypodermic of 
% gr. of morphin. • 

Happy though the results of this combination may 
be in treating amebiasis, the fact should not be over- 



AMEBIC DYSENTERY 287 

looked that emetin is an amebacide and has little to do 
with the healing of ulcerations. Every case of ame- 
biasis should, after this treatment, be considered one 
of ulcerative colitis and so treated from a dietetic point 
of view. At the same time , every effort should be 
made to enhance resistance by change of climate, 
tcnics, etc., to obviate the distressing sequelae charac- 
teristic of the disease. 

It should be remembered that even after the amebae 
have been removed, there still remain unhealed 
ulcers. These should be treated by rest in bed, proper 
diet and local irrigations. The latter serve not only to 
promote healing but also act to prevent relapses. 

Sulphate of quinin is believed by many to be specific 
in its destructive action on the amebae, and is much 
used for irrigating the rectum and colon. It should 
be used in a 1 to 5,000 to 1 to 1,000 solution. Cures 
are believed to have been effected by such irrigations 
in many cases. 

Bates, who has treated a great many of these 
patients successfully in the tropics, has outlined the 
treatment as follows: Complete rest in bed. Give a 
saline purge or other cathartic ; give % grain (.032 gm.) 
injections of emetin daily until two grains (.13 gm.) 
are given; then increase the dose to 1 grain (.065 gm.) 
daily until stool is clear of amebae. Usually a total 
of 5 (.32 gm.) to 6 grains are required. Discon- 
tinue emetin and give large doses of bismuth sub- 
nitrate; one dram ( 4.0 gm.) every four hours during 
waking hours until stools are well formed or some 
constipation supervenes; then decrease dosage grad- 
ually. As soon as effects of saline purge wear off 
begin enemas of saline solution, two or three quarts 
at a time every four hours during waking hours. 
Discontinue when beginning with bismuth, using only 
once or twice a day to counteract constipation. As 
food give sweet milk every two hours during the day 
in quantities of from four to eight ounces. As 
improvement continues gradually add soft diet, as 
poached eggs, slice of dry toast, etc. 

During the Civil War, according to Leidy, and sub- 
sequently as noted by Brem, and by Lawson, ipecac 
has been given by rectum with excellent results in per- 
sistent cases. From 60 to 120 grains are dinsolved in 



288 CHOLERA 

hot water which is kept almost, but not quite, at the 
boiling point for one hour. Twenty-four ounces of 
hot water are used. This is then cooled to body tem- 
perature and injected slowly into the rectum which 
has first been thoroughly cleansed by enemas. of hot 
water. The patient retains the ipecac enema as long 
as possible. 

Several observers have suggested the use of oil of 
chenopodium in much the same way as it is adminis- 
tered for hookworm disease. 

If, in spite of the remedies which have been enum- 
erated, the case still continues rebellious, resort to 
surgical interference may be deemed advisable, and 
appendicostomy may be performed, and irrigation of 
the colon by means of the insertion of an irrigation 
tube through the appendix may be practiced. This, 
however, is a measure almost of last resort. 

Great care and patience are required in the treat- 
ment of this disease, and the treatment should be long 
continued, and after the patient is apparently cured, 
he should be kept under observation for months in 
order that, if a relapse occurs, treatment • may be 
promptly instituted. 

Abscess of the liver is a not infrequent complication. 
Such cases usually recover with emetin treatment if 
it is instituted early. It may be necessary, however, 
to open and drain, especially in the event of secondary 
infection. 

Physicians should not temporize with inefficient 
medical treatment in severe cases of dysentery. There 
is a possibility of obtaining curative results by prompt 
surgical measures such as appendicostomy, etc., which 
may be lifesaving. 

CHOLERA 

Cholera, which is infrequent in the United States, 
has been more widely spread in Europe, due to the 
traveling of large bodies of troops. 

PREVENTION 

Each person can effectually protect himself against 
cholera by extreme cleanliness and avoiding unboiled 
water and uncooked foods. The most important gen- 



TREATMENT OF CHOLERA 289 

eral prophylactic measure is the isolation of the sick. 
The disease starts almost always with diarrhea, and 
although the patient may still feel quite well he is 
already scattering germs in his numerous stools. Even 
before it is possible for bacteriologic examination of 
the stools, the leukocyte count and blood-picture may 
reveal the presence of cholera infection. 

Before eating and especially before preparing food 
the hands should be thoroughly cleansed with soap 
and water. The face and particularly the mouth 
should not be touched by the hands. All fluids should 
be boiled before drinking. If water has to be taken 
raw, the danger of infection can be materially reduced 
by adding a little acid, a knife-tip of citric acid to 
a pint, or 20 drops of liquid phosphoric acid. The 
linen and the dejecta from the sick require, of course, 
thorough sterilization. There is no transmission of 
cholera, typhus or dysentery through the air. 

TREATMENT 

Diarrhea should be checked but castor oil may be 
given to govern the bowel movements and bismuth 
subcarbonate to sooth the intestine is useful. Morphin 
is often needed. 

Brachio, in a recent severe epidemic in Europe, found 
iodin extremely effective, the best method being an 
intraperitoneal injection of a mixture consisting of 
iodin 14 grain, potassium iodid 14 grain, distilled 
water, 20 m. In almost all cases the treatment was 
supplemented with a free use of epinephrin, dropping 
the solution on the tongue. Naame has shown a strik- 
ing analogy between the cholera syndrome and the 
symptoms from defective functioning of the supraren- 
als. He injects epinephrin subcutaneously in doses of 
4 to 6 gm. in twenty-four hours, over several days, 
supplemented by saline infusion. 

Recognizing that the loss of fluids from the tissues 
through vomiting and copious evacuations in the acute 
stage constitute the chief danger in this disease, 
Rogers has recommended rectal injections by the drip 
method of physiologic saline solution. This is kept 
up until the kidneys act freely. If the blood pressure 
is low this may be given intravenously. 



290 GASTRIC ULCER 

GASTRIC AND DUODENAL ULCER 

Ulcers occurring in the neighborhood of the pylorus, 
either on the lesser curvature in the pyloric antrum or 
in the first part of the duodenum, are probably due to 
similar etiology and have the same general character. 
They may, therefore, very properly be considered 
under the same head. Their causation is to be found 
probably to some extent in abnormal conditions affect- 
ing the nerves, the motor activity of the stomach and 
duodenum, the character of the food and the acidity 
of the gastric juice. Rosenow has found streptococci 
which he believes are specific in causing gastric 
ulcer, having a special affinity for the gastric mucosa. 
An acute loss of the mucosa in a healthy stomach is 
rapidly repaired; an acute ulcer of the stomach com- 
monly gets well rapidly. A chronic ulcer behaves dif- 
ferently, indicating that there is some complicating 
factor to keep it from healing. Considerable experi- 
mental work has been done to show that the nervous 
supply of the stomach is necessary to maintain a 
healthy condition of the mucous membrane. Further, 
the experimental work seems to show that a throm- 
bosis of the blood vessels or an "infection" of an area 
of the mucosa is sufficient to cause the destruction 
of a portion of the mucosa and institute an ulcer. 
Ulceration thus produced is favored and the necrotic 
tissue digested and carried away by a gastric juice of 
a high degree of acidity. A very marked influence 
prolonging' the existence of such a lesion is the occur- 
rence of pyloric spasm and the retention of the rem- 
nants of food and gastric contents containing a large 
percentage of hydrochloric acid. In such cases the 
layer of protecting mucus is digested away and the 
ulcerated mucous membrane is exposed to long con- 
tinued action of highly acid and irritating gastric 
contents. 

The process of ulceration in the stomach, in the 
light of our present knowledge, may involve the fol- 
lowing steps : initial weakness or predisposition of the 
tissue; initial injury in the form of abrasion, throm- 
bosis, or necrosis from infection; removal of necrotic 
tissue by active gastric juice; recovery in a normal 



-SYMPTOMS OF GASTRIC ULCER 291 

stomach, but in the presence of pyloric spasm or of 
gastric stasis and the continued action of irritating 
food or secretions a continuance of chronic ulceration. 
In addition anemia must be put down as a complicating 
condition, although not always present. 

FOCAL INFECTION 

In the treatment of gastric and duodenal ulcer the 
experiments of Rosenow indicated the wisdom of 
thorough search for foci of infection and their removal 
if possible. This is especially important in the preven- 
tion of a possible recurrence. 

SYMPTOMS 

■ The symptoms of gastric ulcer are various, but a 
certain number have been considered classic and 
should be kept in mind by the physician as the basis of 
a diagnosis. At the same time the practitioner should 
bear in mind the fact that any of these signs may be 
absent or may fail to present their usual characters. 
The principal symptoms and signs are pain, vomiting, 
hematemesis, melena, tenderness of the epigastrium, 
tender points near the spine; hyperchlorhydria ; and 
roentgenographic findings showing defect in pylorus 
mucosa or duodenal cap. 

Pain in gastric ulcer occurs in attacks with intervals, 
sometimes of days or longer, and is excited by the 
digestive process ; it does not occur immediately after 
taking food, but corresponds to the period of high 
acidity. It is aggravated by coarse foods, but often 
relieved by the taking of bland foods or of alkalies. 
The pain is referred to the epigastrium but this does 
not necessarily indicate the exact location of the ulcer. 

Vomiting is likely to occur after the taking of food 
and has little that is characteristic about it when it 
does not contain blood. 

Hematemesis, or the vomiting of blood, is an impor- 
tant symptom and when the other symptoms are pres- 
ent it may suffice to confirm the diagnosis of gastric 
ulcer. It must be remembered, however, that blood 
may be vomited after it is swallowed from pulmonary 
hemorrhage, or it may be shed into the stomach from 



292 SYMPTOMS OF GASTRIC ULCER 

the bursting of a branch of one or the radicles of the 
portal vein or from an esophageal varix. The latter 
forms of hemorrhage are sometimes the result of high 
blood pressure in the portal circulation in hepatic cir- 
rhosis, etc. 

The presence of large quantities of blood in the 
stools may be discovered macroscopically by their dark, 
tarry character. Such a condition of melena is cor- 
robative of the diagnosis of gastric ulcer, but other 
symptoms should be present ' to indicate that the 
stomach is the source of the bleeding before we should 
give the mere presence of blood in the stools much 
weight in the diagnosis of gastric ulcer. 

A tender point in the epigastrium is found in most 
cases of gastric ulcer. It corresponds to the location 
of the solar plexus and is elicited by slight pressure 
with the finger, differing in this respect from the 
tenderness due to neurasthenia, which requires con- 
siderable pressure to develop it. The tender point in 
ulcer is referred .to a point about midway between the 
ensiform cartilage and the umbilicus, the point being 
constant in one locality and strictly circumscribed. 

Nearly as constant and quite as characteristic are 
tender points felt sometimes on both sides, sometimes 
only on the left, in the dorsal region near the spinous 
processes of the tenth to twelfth vertebra. The dis- 
appearance of these tender points during treatment for 
ulcer is a valuable' indication that the patient is 
improving. 

The diagnosis of gastric or duodenal ulcer may be 
confirmed by the roentgen ray when observed by 
repeated pictures or by fluoroscopic observation. Test 
meals afford only corroborative evidence of the 
existence of an ulcer. Excess of free hydrochloric 
acid is usually present. There is frequently evidence 
of delay in evacuation of the stomach contents, and 
blood, either macroscopic or occult, is present in the 
majority of cases. The presence of occult blood in 
the stomach contents is not pathognomonic. Macro- 
scopic bleeding may be due to injury of the mucosa by 
the stomach tube. The roentgenographic findings are 
gradually assuming increasing importance and while 



TREATMENT OF GASTRIC ULCER 293 

they should not be considered pathognomonic, they 
may be considered almost positive when the other find- 
ings mentioned are also present. 

Occult blood in the feces is of more importance. If 
not constantly found, it is a strong indication of ulcer, 
presumably in the neighborhood of the pylorus. 

As Cheney points out (Jour. A. M. A., 72, 1429, 
May 17, 1919) the diagnosis involves differentiation 
from chronic appendicitis, chronic cholecystitis, gas- 
troptosis, gastric cancer, and other less important ultra- 
abdominal conditions such as tapeworm or hernia. It 
is well known that the gastric crises of tabes may sim- 
ulate ulcer. 

ULCER OF THE DUODENUM 

The principal symptom is pain, more or less local- 
ized in the region of the pylorus, intermittent, occur- 
ring generally about two hours after a meal. In other 
words, this pain occurs when the stomach is more or 
less empty. This pain is more frequently relieved by 
eating some bland food or drinking milk than is the 
pain of ulcer of the stomach. The appetite is generally 
good, and vomiting and other symptoms of gastric 
indigestion are infrequent. Attacks of diarrhea may 
occur, and occult blood is often present in the stools. 
There may be marked hyperchlorhydria. 

TREATMENT 

One of the chief factors in the continuance of ulcer 
seems to be the irritating gastric contents which owe 
their irritating properties largely to their acidity. 
Hence the acid secretion should be reduced as a 
first step by regimen, diet and remedies. 

Not only should the degree of acidity be determined 
and a search made for any other condition of the 
stomach which might cause chronic irritation, but the 
condition of other organs should be interrogated for 
other possible cause of hyperacidity and proper treat- 
ment should be applied. Medicinally the best reme- 
dies are alkalies combined with bismuth; thus one 
may give 



294 TREATMENT OF GASTRIC ULCER 

Gm. 
R Magnesii oxidi. 

Bismuthi subcarbonatis aa 15| or 5 ss 

M. Sig. : Take a small teaspoonful once in three hours. 

If such a powder tends to make the bowels too loose, 
sodium bicarbonate may be substituted for the mag- 
nesium oxid. Atropin or atropin sulphate may be 
given in doses of from 0.00025 gm. (gr. 1 / 250 )> but the 
use of atropin should not be continued too long. 

As hyperacidity seems to increase the ulceration, 
certainly increases the pain, and is likely to increase 
the vomiting, anything that diminishes the acidity is 
good treatment, and a diet free from the substances 
that cause the greatest outpouring of hydrochloric acid 
is the diet of choice. In other words, a diet without 
meat and without meat broths, without toast, and with- 
out any hard particles of food that can scrape or irri- 
tate the inflamed part, should be selected. The Len- 
hartz diet with raw eggs is considered quite sensible 
as giving nutrition and at the same time inhibiting 
the production of hydrochloric acid and tending to 
heal the ulcer. 

The raw eggs are beaten up whole and placed in a 
cup or glass surrounded by ice. The small amount of 
milk given is also served iced in the same manner, and 
the tgg and milk feedings alternate with each other 
every two hours, at first two teaspoonfuls of the egg 
and four teaspoonfuls of the milk. The first day two 
eggs are used and six ounces of milk. The eggs and 
milk are gradually increased from this minimum until 
by the sixth day seven eggs and twenty-two ounces 
of milk are given. From the third day on a little 
granulated sugar is added. At the end of a week the 
number of eggs is reduced and some scraped beef is 
allowed, with soon a small amount of boiled rice. 
During the following week, the second week, the eggs 
may be soft boiled, and four may be administered a 
day, with the milk increased to nearly a quart, sugar 
as before, and scraped beef or chopped chicken and 
rice or bread with a little butter may be gradually 
added and the diet thus varied. Even when the eggs 
are used soft boiled, four should be taken a day. 
Whatever is taken, if solid, it should be very com- 



SIPPY'S TREATMENT OF ULCER 295 

pletely and slowly masticated and, as above stated, at 
first the amounts ingested at one time must be very 
small and taken at intervals of two hours during the 
day. The foods for the first week should be taken 
cold and the next week only warm, never hot. Small 
sips of iced water may be taken as often as desired 
or advisable. 

In view of the hyperacidity, it is well to add to the 
diet as much fat as can well be borne, in the form of 
butter or cream. 

SIPPY TREATMENT 

The Sippy method of treatment consists primarily in 
protecting the ulcer from acid corrosion from the gas- 
tric juice by frequent feedings and the use of alkalis 
given frequently. The patient remains in bed for at 
least the first three or four weeks of the treatment. 
Three ounces of a mixture of equal parts of milk and 
cream are given every hour from 7 a. m. to 7 p. m. 
After a few days soft eggs and well cooked cereals 
are gradually added to the diet. After about ten days 
the patient is receiving three ounces of milk and 
cream mixture every hour, three soft boiled eggs and 
nine ounces of cereal each day. Cream soups of vari- 
ous kinds and vegetable purees, tgg nog, etc. may be 
substituted now and then as desired. Between the 
feedings the patients are given powders of magnesia 
and soda and of bismuth and soda, to neutralize the 
acid secretion. 

It generally seems advisable to give bismuth in large 
doses, at least 2 grams (30 grains) once a day. This 
can be taken stirred up in water or in milk and quickly 
drunk. 

The treatment above suggested generally stops the 
pain. If pain is still severe morphin should be resorted 
to, but with this treatment it rarely will be necessary, 
and the dose required, hypodermatically, is small. 

It must be remembered that the pain is generally 
caused by the free hydrochloric acid and the fact 
that pain disappears gives no evidence that the ulcer 
is healed, but the lesion may still continue in a latent 
state and make its presence felt by symptoms when 
the increased acidity of a new attack sets up renewed 



296 HEMORRHAGE IN GASTRIC ULCER 

irritation. Sippy's practice is to give alkali enough 
not only to relieve the pain, but also to neutralize all 
the free acid and keep it neutral during the greater 
part of the twenty-four hours. 

The patient should not get up to urinate or for the 
bowels; a bed-pan should be used. If the patient is 
constipated the bowels may be moved by the rectal 
injection of a half ounce to an ounce of glycerin with 
an equal amount of water, and soap suds could be 
used if needed. 

As these patients are already short on iron and for 
a number of days are to receive no meat, it is advis- 
able to give the saccharated oxid of iron (eisen- 
zucker) 3 grains in tablet form twice a day. The 
patient should thoroughly crush the tablets with the 
teeth before swallowing. 

If after a month of this treatment the patient cannot 
normally convalesce and be apparently cured, in other 
words, if the symptoms quickly return, an operation 
should probably be recommended as the future of such 
a recurrent case is uncertain. Recurrent severe hem- 
orrhage should cause operation and of course when 
there is perforation operation is immediately neces- 
sary. 

HEMORRHAGE 

In case of hemorrhage from the stomach perfect 
quiet must be insisted on. A hypodermic injection 
of morphin and atropin in full dose should be admin- 
istered. If the symptoms show that hemorrhage is 
persistent 1 c.c. (15 minims) of a 1 : 1,000 adrenalin 
chlorid solution in 30 c.c. (1 ounce) of distilled water 
should be given and followed in half an hour by from 
50 to 100 c.c. (about 2 to 3 ounces) of a 10 per cent, 
solution of sterile gelatin. Ordinarily food should 
be withheld from 48 to 72 hours, no food being given 
even by the rectum. As nutrient enemata have been 
shown to increase the flow of gastric juice, the first 
enemata should be normal salt solution and later pep- 
tonized milk and egg may be used. 

During the treatment of gastric ulcer the feces 
should be frequently examined for occult blood. When 
blood ceases to be present in the feces we have an 
indication that the healing of the ulcer is progressing 



HYPERACIDITY 297 

and it is justifiable to use larger quantities of food and 
that of a more solid character. In case bleeding reap- 
pears after it has been absent for some days this 
should be taken as indicating the propriety of lessening 
the amount and simplifying the character of the food. 
Some physicians believe that morphin should never 
be given to relieve the pain with hemorrhage, because 
it tends too increase the stasis and hyperchlorhydria 
that is present in ulcer. Gelatin may be given or any 
of the other colloidal solutions such as acacia may be 
utilized. It may be advisable to consider seriously the 
question of blood transfusion or the use of some of 
the hemostatic preparations described under the sub- 
jects of hemophilia and purpura. 

OPERATIVE INDICATIONS 

Dr. William H. Mayo has caustically remarked that 
these patients should be operated on after they have 
had nine complete medical cures. Others have said 
there is no medical treatment of gastric or duodenal 
ulcer. The subject is one of the most debated ques- 
tions in medical science today. Certainly the patient 
should have the benefit of the most competent advice 
available when the indications seem doubtful. 

When there is marked tenderness at a location 
aside from the region of tenderness common to the 
ordinary ulcer or if there should be a slight rise of 
temperature and an increased leukocytosis one may 
entertain the suspicion of an approaching perforation. 
In such case no delay should be permitted before open- 
ing the abdomen and ascertaining the true condition. 
According to Billings, surgical treatment is indicated 
when the unhealed ulcer or the scar produces deformi- 
ties which persistently interfere with gastric and intes- 
tinal function. 

HYPERACIDITY 

Practically this term means cases of increasing gas- 
tric disturbance, at various intervals after meals, or 
the ingestion of special kinds of food; heartburn is a 
common accompaniment. Tests with the stomach-tube 
reveal either hyperacidity or hypersecretion, and the 
latter may be separated into a digestive and a continu- 
ous type. The latter, when appearing periodically, is 



298 HYPERACIDITY 

known as Reichmann's disease or gastrosuccorrhea. 
Pawlow's opinion that pure gastric juice has the same 
percentage of hydrochloric acid, must in the light of 
recent research be abandoned unless we assume that 
the superficial epithelium produces concentrated alka- 
line fluid, together with pure gastric juice, which is 
paradoxical according to Gregerson. Schmidt con- 
cludes that the stomach secretion must vary under 
pathologic conditions. Nervous influences come into 
play and the question arises whether or not there is 
an etiologic relationship between the hyperacidity of 
the stomach and the subjective symptoms. The 
anamnesis must not be depended on without the use 
of the stomach-tube. Still more important is the ques- 
tion whether this hyperacidity occurs as a disease 
dependent only on nervous causes, or whether it always 
has some organic lesion as a cause. The old notion 
that it was a pure gastric neurosis has changed on 
account of the rediscovery of duodenal ulcers. The 
purely nervous cases are less to the fore, but we would 
be premature in entirely denying hyperacidity in some 
cases as a unit per se. 

Hyperacidity is now generally considered a symp- 
tom of disease rather than a disease itself. It fre- 
quently occurs in the sedentary and overworked and 
in connection with other abdominal disorders, such as 
appendicitis, gallstones, enteroptosis, uterine displace- 
ments, etc. It is also an early sign of the beginning of 
hyperthyroidism and of tuberculosis, and it may be due 
to ear troubles or eye-strain. It is a complex affair to 
deal with, and hence calls for a correct diagnosis of the 
causal conditions, with the removal of which the hyper- 
acidity often disappears. In addition to these general 
or exciting causes, the local conditions in the stomach 
must be considered. Any one who has had hyper- 
acidity for any length of time will have certain path- 
ologic changes in the gastric mucosa, hypersecretion 
and hyperesthesia, and we often find pylorospasm, 
hypermotility or gastroptosis. Schmidt classifies hyper- 
acidities as follows : "1. Chemical hyperacidity with a 
normal quantity of gastric content after a Boas-Ewald 
test breakfast. 2. Chemical acidity combined with 
hypersecretion or with a continued secretion. Here 



TREATMENT OF HYPERACIDITY 299 

the quantity of gastric content is abnormally and con- 
stantly large. 3. Chemical hyperacidity combined with 
hypersecretion and hyperesthesia. 4. Clinical or 
symptomatic hyperacidity with hyperesthesia. In this 
class of cases we have all the subjective symptoms 
of a chemical hyperacidity. In these cases we find a 
normal total acidity or even a subacidity. The symp- 
toms are due to the hyperesthetic condition of the 
gastric mucosa, which is painful in a normal or even 
subnormal acid content. 5. In this class we may find 
any one or a combination of the foregoing, together 
with pylorospasm, hypermotility or peristaltic unrest." 

TREATMENT OF HYPERACIDITY 

The principal point is, not to confine the active 
treatment entirely to the stomach, but also to calm and 
strengthen the nervous system. Some patients are 
best treated by being sent at once to a hospital or 
sanatorium. Naturally, we try first to reduce the secre- 
tion. Atropin acts in this way, but its continuous use 
is not advisable, nor is that of the alkalies, which may 
irritate the stomach glands. Diet is very important, 
and foods that act as secretory stimulants, like spices, 
coffee, etc., should be avoided. As to special diets, it 
is difficult to keep them up for any length of time. 

Schmidt offers the following rules : All food must be 
thoroughly cooked and thoroughly minced. The stom- 
ach must come to rest at least once during the twenty- 
four hours and the times of the meals changed to 
secure this. Drinking should be generally diminished 
and restricted to times when the stomach is not filled 
with food, especially in cases of ptosis. If the condi- 
tion is severe or combined with ptosis, he makes the 
patient stay in bed for two weeks, and this he con- 
siders important. Sometimes hot compresses are used 
to bring relief — twice daily for two hours. At night 
they are replaced by cold hydropathic compresses. 
Washing the stomach is indicated only when the 
hyperacidity is based on catarrh. Temporary relief, 
however, will always be afforded by the administration 
of an antacid, and the burning, distress, pyrosis, and 
flatulence that may be present will all be made imme- 



300 TREATMENT OF HYPERACIDITY 

diately better by the administration of 1 gram (15 
grains) of bicarbonate of soda. Such treatment is, 
of course, purely symptomatic. If it is advisable to 
give bicarbonate of soda, which is perhaps the best 
of all the antacids, three times a day, before meals, the 
dose should be smaller, perhaps generally 0.50 gram 
(7% grains). It will act, as above stated, as a gastric 
sedative and will soothe the irritated mucous mem- 
brane, will cause a quicker outpouring of the hydro- 
chloric acid, and will thus hasten the completion of 
the stomach protein digestion; all of which will tend 
to make the disturbance better. If gastritis is present, 
no one treatment is perhaps more successful than the 
combination of bismuth and soda, as: 

Gm. 

IJ Bismuthi subcarbonatis 201 or 3v 

Sodii bicarbonatis 10] 3 iiss 

M. et fac chartulas, 20. 

Sig. : A powder three times a day, before meals. 

Bassler has suggested the following formula : 

Gm. or C.c. 

I£ Magnesii oxidi 10 3 iiss 

Bismuthi subcarbonatis 20 or 3v 

Syrupi acaciae q.s. 

Aquae destillatae q. s. ad 200 fl§ viii 

M. et sig. : Take orie tablespoonful as required after meals, 
plain or in water. 

A glass of hot water taken a half-hour before the 
meal to wash off the mucus and to deplete the inflamed 
gastric mucosa is, of course, excellent treatment. 

If the antacid is given after a meal the digestion of 
the starchy foods will go on longer than usual, on 
account of the alkali keeping the contents of the stom- 
ach longer alkaline, viz., free hydrochloric acid or a 
large amount of acid peptones will not so soon be 
present to inhibit further salivary digestion. 

If with the dyspepsia, or gastritis, constipation is 
present, some magnesium oxid should be added to the 
above prescription or substituted for the sodium bicar- 
bonate. Also in hyperacidity the precipitated carbon- 
ate of lime is used, and is often a most successful 
treatment. 

If an antacid is indicated and diarrhea is present, 
it is advisable to use lime water. 



CATARRHAL JAUNDICE 301 

Jacobson argues that we should exclude the chlorids 
from the diet in hyperacidity since these are the source 
of acid. Even after a prolonged salt- free diet, the 
tissues still supply chlorin to the gastric glands. In 
man the gastric juice is resorbed in the intestine, and 
the same dose of salt can be used again indefinitely for 
the secretion of gastric juice. The method of attack, 
then, is to use a well-balanced diet save for the lack of 
chlorin. Foodstuffs should be either naturally poor in 
chlorin or freed from it by boiling. 

SIMPLE CATARRHAL JAUNDICE 

This condition is due to a blocking, from more or 
less inflammation and swelling, of the common bile 
duct. While this duct alone may be involved, it is 
generally secondary to inflammation of the duodenum. 
This irritation and inflammation of the duodenum 
may itself be secondary to a simple gastritis, and the 
whole condition may be a sequence of serious mal- 
digestion or infection and irritation from some deterio- 
rated or toxin-bearing food. The ingestion of too 
much alcohol or of too much simple irritant, as mus- 
tard or rich sauces, or of some irritant drug or an 
irritant poison may cause secondarily the condition of 
simple catarrhal jaundice. In a person who has had 
this condition once, or is predisposed to abdominal 
congestions, chilling of the abdomen, either from a 
sudden change in temperature, or from exposure of 
an insufficiently clothed abdomen to cold air, may 
cause duodenal congestion and catarrhal jaundice. 

This kind of jaundice is most likely to occur in the 
season of the year in which there are sudden, changes 
to lower temperature, especially in the fall and in 
the early spring following warm periods. Whatever 
may be the exciting cause, cold frequently plays a con- 
tributing part in the development of the disease. 

A true epidemic form of this disease has been 
termed Weil's disease, and has been accredited to a 
spirochete known as Spirochaeta icterohemorrhagiae . 
This is ushered in with a high fever, lasting one or two 
weeks, with a gradual decline in the second week, and 
is attended with considerable prostration. Albumin 
has been found in the urine, and the spleen has been 



302 TREATMENT OF JAUNDICE 

enlarged. Whether the simple catarrhal jaundice so 
frequently seen is a sporadic form of such an infection 
has not been determined. Until they have been proved 
to be related, it would seem well not to consider simple 
catarrhal jaundice as the disease described by Weil. 

Simple catarrhal jaundice generally develops insid- 
iously ; rarely shows any increase of temperature, and 
if there is a fever it is very low, and often the tempera- 
ture is subnormal; there is considerable prostration; 
slow pulse ; entire loss of appetite ; some nausea ; often 
vomiting; and there is likely to be constipation, 
although there may be diarrhea. The head feels dull, 
or there is real headache. The tongue is heavily 
coated, either brown or yellow. The breath is very 
bad, and there is a bad taste in the mouth. There, is 
soon bile in the urine, and there may be traces of 
albumin. Jaundice may be present when the patient is 
first seen. Soon the stools are clay colored, and the 
skin is dry and irritated sufficiently to cause itching. 
The perspiration generally stains the clothing. There 
is much mental depression, and inability to do mental 
work, but generally not much abdominal pain. The 
jaundice usually last two, three or even four weeks; 
if it lasts much longer than four weeks, some other 
cause for the jaundice than a simple inflammation must 
be sought. 

The more at rest the patient is, the quicker will the 
jaundice generally subside. In the beginning a dose 
of calomel, in amount considered sufficient, should be 
given, followed by a saline. A gram of bismuth sub- 
carbonate and a gram of sodium bicarbonate may 
be given every three hours during the. day for two 
or three days, and then three times a day, before meals, 
for a few more days. The bowels must be moved 
daily by some simple saline or laxative water. If there 
is much epigastric tenderness and soreness, or if there 
is nausea, milk of magnesia in teaspoonful doses every 
three or four hours, in hot water, is advisable. The 
patient should be given plenty of water to drink. Hot 
water is also advisable. 

For the first twenty-four hours, nothing but water 
may be given, unless food is especially desired. On 



DIET IN JAUNDICE 303 

the following day the nourishment should be bouillon 
or hot broths, tea, toast, thin oatmeal gruel, or some 
other simple thin cereal. Malted milk may be given, 
and in another day or two a poached egg or two, if 
they are well tolerated. All fats and milk, except 
possibly skimmed milk, should be avoided in catarrhal 
jaundice. It is a mistake to consider milk a good food 
in this condition. No liquid should be given cold, and 
no cold food should be given ; anything cold taken into 
the stomach in this condition is probably disadvan- 
tageous. As soon as the sodium bicarbonate in com- 
bination with the bismuth subcarbonate is given less 
frequently, an alkali should be given, as potassium 
citrate, 2 gm., in wintergreen water, 10 c.c, three times 
a day, after the main nourishments. 

As stated above, the more at rest the patient is (in 
other words, the more he lies down) the better. There 
is less abdominal congestion, and the circulation in the 
congested region is improved. As an aid to resorption 
of the exudate in these swollen parts, abdominal 
warmth is advisable, and an electric heating pad or 
hot water bottle kept on the abdomen for hours at a 
time is good treatment. When the patient is up and 
about, the abdomen should be kept extra warm by 
flannel or absorbent cotton. 

To relieve internal congestion and to increase the 
secretion of the skin and stop itching, it is advisable 
to have a daily hot bath. It is of advantage especially 
in removing. the irritating crystals that occur on cer- 
tain parts of the body from the perspiration in this 
condition. 

As the patient improves, the diet can be enlarged 
with oranges, baked potatoes, rice and more meat, still 
withholding the fats, except that foods with cooked 
milk, as custards, may be well digested. 

If the jaundice lasts more than ten days or two 
weeks, ammonium chlorid in half-gram doses, three 
times a day, after meals, may be given. Ammonium 
chlorid apparently increases the secretion of the 
mucous membranes. Probably it increases the secre- 
tion of the bile ducts as it does that of the bronchial 



304 CONSTIPATION 

tubes. It may be a valuable treatment in this condi- 
tion, when the improvement is slow. The following 
prescription may be utilized : 

Gm. or C.c. 

B Ammonium chloric! 10| 

Syrup of citric acid 25| 

Water up to 100| 

Mix and label: A teaspoonful, in water, three times a day, 
after meals. 

INTESTINAL STASIS— CONSTIPATION 

The term intestinal stasis has of late years been 
used to include what was formerly classed as consti- 
pation, but with an extension to more serious cases 
which require surgical treatment. Intestinal stasis 
includes all cases in which the contents of the bowel 
fail to move in a normal manner, whether the cause be 
a mechanical obstruction or a functional failure due 
to the character of the intestinal contents or to the 
functional inactivity of intestinal musculature. The 
stasis may occur at various locations in the gastro- 
intestinal canal, but the usual location in the cases 
under consideration are stasis in the lower part 
of the ileum, stasis in various sections of the 
large intestine and stasis in the rectum. Hindrance 
to the evacuation of the feces may be due to a paresis 
of the rectum or sigmoid, brought on either by repeated 
distention with feces or by the use of daily large rectal 
enemas. In these cases help may be obtained by daily 
diminution of the bulk of water used. A very fre- 
quent cause of constipation is insufficiency of feces 
resulting from the general insufficiency of the food 
taken or from the fact that it contains too little of the 
indigestible vegetable matter which favors the evac- 
uation of the bowels. In such cases the feces are hard 
and dry, from the fact that during their stay in the 
large intestine the water has been absorbed to an 
undue extent. This form of constipation must be 
treated by proper diet. 

■ 

DIET 

The constipated person should aim to add to his 
diet a larger quantity than normal of fluids, either in 
the form of water or perhaps of buttermilk. Tea 



DIET IN CONSTIPATION 305 

should be avoided because it contains tannin 
which may, by its astringent action, counteract the 
good effect of the larger quantity of liquid. Liquids 
should be given not only at meal times but in the inter- 
vals, in which case they serve better to replace the 
water absorbed from the large intestine. The diet 
for constipation should also contain as large an 
amount of fat as the patient can tolerate. The 
amount of vegetables which contain considerable 
quantities of cellulose should also be increased. This 
means plenty of vegetables. It is possible, however, 
easily to carry to extremes the eating of indigestible 
substitutes which add bulk to the diet. The accumu- 
lation of such masses in the bowel, even though evacua- 
tion is easy, does not have a favorable effect. Fruits 
should be given freely, except the astringent fruits. 
The amount of water taken depends on the patient's 
habits and the condition of the circulation. A patient 
who is muscularly active should drink more water than 
the one whose life is sedentary. A glass of cold water 
drunk in the morning while dressing is a great help 
to a physiologic movement of the bowels directly after 
breakfast. 

LAXATIVE FOODS 

The vegetables that are especially useful in chronic 
constipation are spinach, peas, cauliflower, cabbage, 
asparagus, salads, onions, celery and tomatoes. The 
cereals of importance are oatmeal and cornmeal, as 
well as graham, rye, whole wheat and bran breads. 
The following are also classed as laxative foods: 
Honey, cider, molasses, apples, pears, peaches, oranges, 
prunes, dates and figs. Buttermilk is preferable to 
sweet milk. 

HABIT 

The importance of establishing regularity of bowel 
action cannot be overstated. In a comprehensive study 
of the whole subject Thaysen concludes that this factor 
is of greatest importance. He gives his patients a 
printed card of directions as to diet and habit so that 
a regular time may be established. 

The patient should go to stool every morning at the 
same hour whether the desire is present or not, and 
should attend to the matter at hand, and, especially 



306 MASSAGE IN CONSTIPATION 

should not read for diversion. It is especially valu- 
able to use a seat that is not too comfortable and to 
be able to flex the knees well up toward the abdomen ; 
if the seat is too high a footstool may be used. 

Abdominal massage, calisthenics, regulated exercise, 
walking, rowing, riding, golf playing, or any other 
muscular exercise that seems advisable should be 
ordered for the patient of sedentary habits, and it 
must be urged on him that if the habit of constipation 
is not now cured the future promises intestinal indi- 
gestion, dyspepsia, imperfect action of the liver, imper- 
fect bile, nervous irritations, kidney irritations, and 
early cardio-vascular-renal disease; i. e., arterioscle- 
rosis, weakening of the heart, and chronic interstitial 
nephritis. 

MASSAGE 

Before any severe exercise or any abdominal mas- 
sage is ordered, or advised, a careful abdominal exam- 
ination should be made and the physician assured that 
there are no inflammatory conditions present, as 
chronic appendicitis, gallbladder, pelvic or other dis- 
turbances. 

Manual massage may be applied to the abdomen 
from fifteen to twenty minutes, beginning with light, 
circular stroking of the abdomen about the umbilicus, 
first having lubricated well the parts with olive oil. 
The course of the colon is gradually massaged deeply, 
all fecal masses broken up and moved down toward 
the rectum. When massage is deemed inadvisable or 
inconvenient, faradic electricity may be used. A large 
electrode may be over the lumbar or sacral spine and 
the other is moved over the abdomen, stroking from 
right to left. The duration of the treatment and 
strength of current should vary with the result on 
the patient. A vibrator may also be used gently over 
the abdomen. 

MEDICINAL TREATMENT 

Probably one of the best medicinal treatments of 
constipation consists in the administration of the 
fluidextract of cascara sagrada or some form of 
aloes or aloin. Sometimes podophyllin may be used 



SPASTIC CONSTIPATION 307 

separately or combined with other laxatives. There 
are no other laxatives or cathartics so likely to 
benefit constipation as these drugs. Whichever one of 
these is used, it should be given, week by week, in 
gradually diminishing doses. Whether they should be 
given in small doses three times a day, or larger doses 
once a day depends on the conditions. Generally, the 
patient, not being sick and not willing to be bothered, 
and with the intent of having a stool after breakfast, 
and the medicine requiring a certain length of time to 
act, directly after supper or at bedtime, in one dose, 
is the best treatment. However, even with the best 
possible care, when these drugs are given, some 
patients require a dose daily for months and even 
years, and can not obtain a stool without it. This is 
generally not due to the action of the pill on the mind, 
as the substitution of an inactive tablet will prove. 

Perhaps the next best laxative is phenolphthalein. 
This drug generally acts well and, if given in tablet, 
should be crushed with the teeth before swallowing, 
as it apparently acts better when well granulated. It 
should not be used too long as it may cause colon and 
rectal irritation. 

In the simple constipation that is now being dis- 
cussed it is inadvisable to resort regularly to enemas of 
any kind or to more brisk cathartics than those above 
mentioned or to saline cathartics. 

Of late liquid petrolatum has achieved great vogue, 
as it acts merely as a lubricant, is inert, easy to take 
and supposedly does not form a habit. In large doses 
it may cause unpleasant rectal oozing. 

A good general discussion of the whole subject 
appears in Fantus' "Useful Cathartics," published by 
the American Medical Association. To those especially 
interested a perusal of this book is recommended. 

SPASTIC CONSTIPATION 

This form, which is usually reckoned as a distinct 
variety, is characterized by the distress experienced 
during the act of defecation and by the appearance of 
the stools, which are narrow, sometimes of the caliber 
of a lead pencil, and often covered with mucus. 



308 INTESTINAL PTOSIS 

Sometimes separate masses of mucus in the form of 
strings or membranes are passed with the stool or at 
times when no stool is passed. This spastic form 
usually occurs in neurotic patients and the whole clin- 
ical picture is dominated by the nervous element. 
These cases should receive treatment appropriate to 
their nervous condition and they are also benefited 
locally by oil enemas, given as a rule on alternate 
evenings. The technic of administering the oil is very 
simple. About 250 cubic centimeters of cottonseed 
oil, as warm as can well be borne, are injected through 
a funnel attached to a colon tube and allowed to remain 
in the rectum until the next morning. Patients unac- 
customed to these injections should put on a large 
diaper after the enema to obviate the danger of the oil 
leaking through the anus. It is necessary to recog- 
nize a constipation of psychic origin and one due to 
habit, which must be treated by suggestion and educa- 
tion with appropriate hygienic aids. 

What has been said above refers to the treatment of 
a symptom and only in the mildest cases is it curative 
in the sense of being addressed to the underlying 
lesion. Even in cases of spastic constipation which 
have been interpreted as pure neuroses it is probable 
that an anatomic basis is present in the form of a 
colonic catarrh which is greatly aggravated by the 
nervous condition. Following Lane, a large number of 
surgeons have explained the symptoms in a large cate- 
gory of abdominal and constitutional disorders as due 
to a mechanical hindrance to the passage of the intes- 
tinal contents and the consequent putrefaction occur- 
ring in the bowel. 

Ptosis of the various parts of the intestine are 
believed to form the basis of the obstruction from 
which the abnormal symptoms arise. In other cases 
it is supposed that adhesions, inflammatory membranes, 
etc., cause bends and kinks in the intestine which pre- 
vent the free movement of the intestinal contents. 
Unanimity in the interpretation of these facts has not 
been reached by clinicians. A number, including Ein- 
horn, Bastedo, Wilcox and others, consider that the 
bands and ptoses do not account for the stasis inas- 
much as the symptom of stasis is frequently intermit- 



SYMPTOMS OF STASIS 309 

tent and persons with equal mechanical hindrances may 
be free from symptoms indicating the occurrence of 
putrefaction. 

Einhorn refers the doctrine of ptosis to Glenard. 
The theory of putrefaction and its resultant autoin- 
toxication is due to the teaching of Bouchard, Combe 
and others. This theory is made by Lane and his disci- 
ples the foundation for their plan of treatment. The 
digestive canal is called "a drainage tube" and com- 
pared to a sewer system in which any clogging must 
cause disaster. It has been asked if our body is 
resourceful in adequately fighting enemies that it has 
never before encountered— pneumonia, typhoid fever, 
etc. — how much more must we expect from it in the 
way of every-day defenses. It is surely well fitted to 
debar the entrance of harmful digestive products 
through the intestinal wall, for this is a continuous 
happening. 

Unless there is a real mechanical obstruction or a 
definite organic lesion interfering with the intestinal 
current, a temporary delay of the contents may not 
be significant. It may even serve to make absorption 
more complete. 

The usual simple habitual constipation does not 
cause autointoxication. As is well known, a patient 
may have no bowel movement for several days and 
still present no abnormal symptoms. The symptoms 
frequently associated with chronic constipation may 
be ascribed to nervous disturbances, and not to auto- 
intoxication. Reassurance and nerve sedatives in such 
cases will often do more good than drastic measures. 

In mild cases Lane, following Glenard, recommends 
an appropriate abdominal supporting bandage. In the 
severer type Lane recommends operative measures — 
ileocolostomy or colectomy. With this radical plan of 
treatment most clinicians and some eminent surgeons 
do not agree. 

SYMPTOMATOLOGY 

The symptoms of the milder forms of intestinal 
stasis are the same as those commonly attributed to 
constipation. Much of such, symptomatology may 
result from the effect of ptosis on a neurotic constitu- 
tion and it is probably erroneous to attribute all symp- 



310 DIAGNOSIS OF STASIS 

toms observed in such patients to intoxication from 
the intestines. A proper estimate of the effects of 
the various factors influencing the clinical course of 
such cases is important, as indicating the relative 
importance to be assigned to different measures 
employed. Other symptoms are mechanical from the 
pressure of the delayed fecal masses, still others may 
result from dragging on the adhesions or bands con- 
necting different organs ; still others are due to nervous 
reflexes from irritation or inflammation of the mucous 
membrane of the colon. Lastly there are symptoms of 
actual organic lesions which may result from putre- 
factive changes in the contents of the colon. Such 
symptoms in severe cases may form a serious clinical 
picture. 

DIAGNOSIS 

It is fortunate that we possess means of making an 
accurate diagnosis of intestinal stasis by means of 
roentgen-ray examinations, either radiographs or flu- 
oroscopic examinations. In this way the length of 
time that is required for food to pass through the 
different sections of the intestine can be determined, 
and it may be learned at what point the delay, if any, 
occurs. Abnormalities in the contour and position of 
the different parts of the intestine can also be deter- 
mined in the same way. The existence of intestinal 
putrefaction is shown with certainty by the appearance 
of indican in the urine. The extent of the putrefactive 
changes are not, however, easily estimated in this way. 
If, on shaking out the urine with chloroform after 
treating it with Obermeyer's reagent (a solution of 
ferric. chlorid in strong hydrochloric acid, two parts to 
one thousand) the chloroform has a deep blue color, 
a considerable amount of indican is present, and it is 
justifiable to assume that there is a considerable degree 
of intestinal putrefaction. 

TREATMENT 

The treatment of mild degrees of intestinal stasis 
is the treatment of constipation as previously outlined. 
To this should be added such mechanical supports as 
are necessary to obviate the effects of ptosis of the 



HOOKWORM DISEASE 311 

intestine. As a laxative agent Lane has strongly rec- 
ommended liquid petrolatum. Bastedo and more recent 
literature generally object to the use of the ordinary 
drug laxatives and recommend the use of agar-agar 
or of liquid petrolatum. 

Surgical Treatment. — The question of what surgical 
measures should be resorted to and the proper time 
to apply them is very important. Medical treatment 
should be given a thorough trial. If medical measures 
fail, operation may be resorted to. Moynihan believes 
that nothing short of colectomy offers a substantial 
chance of cure. The part of the gut that needs 
removal is, he thinks, the last part of the ileum, the 
cecum and the ascending colon. 

HOOKWORM DISEASE 

This disease is found in all tropical and southern 
temperate zones ; in the United States southward from 
the Potomac River latitude through to the Pacific 
coast. The symptoms are laziness, lassitude, weakness, 
loss of physical and mental ability and vitality; loss of 
weight and anemia. Children do not properly grow 
and adults become shiftless, incompetent, and poverty 
stricken, and they, with their families, become a tax 
on the community. Hence hookworm eradication is 
an economic question. 

The hookworm was discovered in Porto Rico by 
Major Ashford, Surgeon of the United States Army, 
but to Dr. C. W. Stiles of the United States Public 
Health Service belongs the honor of having found the 
worm in the southern states and of having shown 
that it differs generically from the Old World worm, 
but that it causes the same symptoms. The American 
type of worm is called Necator Am eric amis. 

The disease can be discovered by giving the specific 
treatment in a suspected case and then sifting or wash- 
ing the stools through cheese cloth, when worms will 
be found, if present. Billings and Hickey (Jour. A. 
M. A., Dec. 23, 1916, p. 1208) describe an excellent 
simple technic for this purpose. 



312 TREATMENT OF HOOKWORM DISEASE 

TREATMENT 

The treatment is to give little or no supper, and 
at bedtime a dose of magnesium sulphate. In the 
morning, as soon as the bowels have moved freely, 
one-half the dose of thymol, in capsules, is given, and 
in two hours the remainder of the thymol. Two hours 
later another dose of magnesium sulphate is admin- 
istered. After movements of the bowels from this 
dose food may be taken, but only coffee or tea, with- 
out milk, should be allowed during the period of the 
treatment, namely, until the thymol has supposedly 
all passed out of the body. Absorption of thymol is 
not desired, as it may cause unpleasant symptoms. 
Alcohol and oils should not be given either before, 
during or even soon after the treatment. For one 
hour after taking the thymol the patient should lie 
on his right side to hasten the passage of the drug 
and liquid through the pylorus into the intestines. 

The dose of thymol depends on the age, but is large. 
Ferrell suggests 4 gm. (60 grains) for an adult dose 
(that is, from 20 years of age. upward). Doses for 
children and youth may be readily estimated by the 
following formula, namely: At 15 years, % of the 
age, % of the adult dose; at 10 years, y 2 the age, 
i/2 the dose; at 5 years, % the age, y 4 the dose; at 
21/2 years, y 8 of the -age, % of the dose. If the 
patient is much underweight for his age, the dose 
should be reduced accordingly. The thymol should 
be powdered and placed dry in capsules. One-half 
the dose decided on is given at 6 a. m. If the bowels 
have been well moved from the dose of magnesium 
sulphate the night before, the other half of the dose 
of thymol should be given at 8 a. m., both doses being 
taken with plenty of water. Ferrell adds sugar of 
milk in equal parts to the thymol, and says he thinks 
the drug acts better. 

In one or two weeks the treatment should be 
repeated, unless the microscope shows the feces to be 
free from the parasite and its eggs. Sometimes a 
third and even a fourth treatment may be needed. 
The action of the thymol may be hastened by (at the 
moment of swallowing) uncapping the capsules. 



CHENOPODIUM IN HOOKWORM DISEASE 313 

Thymol when absorbed acts like phenol, but it is 
slowly dissolved by the gastro-intestinal fluids and 
hence, is absorbed slowly. Any oil or fatty substance 
hastens its absorption. Convulsions are probably not 
often caused by thymol poisoning, but great weakness 
and finally collapse are the gross subjective symp- 
toms. Objective symptoms of its undesired absorption 
are albumin and even blood in the urine. Fatty 
degeneration of the liver and congestion of the kid- 
neys and lungs are pathologic findings. 

To forestall any possible great absorption of thymol 
after large doses are administered in hookworm dis- 
ease, a brisk cathartic (Epsom, Glauber's, or Rochelle 
salt) should be given and repeated, if free catharsis 
does not occur within a few hours after taking the 
thymol. Castor oil, or any other oil, should of course 
not be the cathartic used. If symptoms of poisoning 
occur, stomach-washing, colon-washing, and sodium 
sulphate or potassium and sodium tartrate should be 
the means used to promote elimination. Strong black 
coffee should be given, and hypodermic injections of 
atropin, strychnin, and pituitary extract should be 
administered and the patient should be surrounded by 
dry heat. Later, any kidney congestion should be 
treated as an acute nephritis. 

Except as a specific for hookworm, thymol should 
probably never be used internally. As a bowel anti- 
septic it is too dangerous a drug to be used repeatedly, 
unless the dose is too small to be of any value. 

Ferrell's dosage for adults for hookworm disease 
is as follows : 

Gm. 

B Thymolis 4| or gr. lx 

Fac capsulas siccas 10. 

Sig. : Take 5 capsules, with plenty of water, in the early 
morning, as soon as the bowels have moved. Take the 
other 5 capsules in two hours. Two hours later take % 
ounce of Epsom salt, which should be repeated if it does not 
act in four hours. 

USE OF CHENOPODIUM 

The investigations of the United States Public 
Health Service have shown that oil of chenopodium 
(American wormseed oil) is also efficient in this 



314 CHENOPODIUM IN HOOKWORM DISEASE 

disease. (Public Health Reports, reprint No. 224, 
Oct. 2, 1914, by M. G. Motter.) 

Wormseed oil seems to paralyze or stupefy rather 
than kill the hookworm; therefore it is very essential 
that soon after such action has occurred, a cathartic 
should be administered to cause evacuation of the 
worms before they can recover their vitality. Unlike 
male fern and thymol, castor oil may be administered 
with this drug. It will be remembered that any oil is 
likely to cause a dangerous amount of male fern and 
thymol to be absorbed. This is not true of worm- 
seed oil. 

The doses of oil of chenopodium suggested in this 
pamphlet are about 1 drop for every year of age up to 
fifteen. The drug is well administered in a teaspoonful 
of granulated sugar, every two hours, for three doses. 
Two hours later, a child of ten years, for instance, 
should receive a tablespoonful of castor oil with one- 
half a teaspoonful of spirits of chloroform. The dose 
of the castor oil and of the chloroform should vary 
according to the age of the patient. 

The routine use of oil of chenopodium was found 
very satisfactory by Billings and Hickey and many 
others. The following method of administration was 
utilized for adults : 

Preparatory treatment: At 7 a. m. magnesium sul- 
phate, saturated solution, 60 c.c, is given. At 7 p. m., 
sodium sulphate, saturated solution, 90 c.c. The next 
morning chenopodium is commenced, proceeding as 
follows : 

7 a. m., oil of chenopodium, 15 drops. 
9 a. m., oil of chenopodium, 15 drops. 
11a. m., oil of chenopodium, 15 drops. 

1 p. m., castor oil, 18 c.c. ; chloroform, 2 c.c. 
1 :30 p. m., plain castor oil, 30 c.c. 

2 p. m., a cup of hot tea. 

The dosage of oil of chenopodium from 6 to 7 years 
is 5 drops ; from 8 to 9 years, 7 drops ; from 10 to 11 
years, 10 drops; from 12 to 15 years, 12 drops; 16 
years and over, and under 60 years, 15 drops. 



CHENOPODIUM IN HOOKWORM DISEASE 315 

A varying amount of the stock solution of chloro- 
form-castor oil mixture is used, depending on the age 
of the patient, and sufficient castor oil added to make 
the total dose 20 c.c. In the second column of the 
above table is indicated approximately the amount of 
chloroform per dose in minims. The stock solution 
contains : chloroform, 2 c.c. ; castor oil, 18 c.c. ; one 
dose is 20 c.c. This dosage is to be used in conformity 
with apparent age only. 

On the sixth day after treatment the stool is exam- 
ined and, if found positive, another course of treat- 
ment is given and the stool again examined at the end 
of the second six days. It is not necessary to place 
limitations on the diet as is the case in using thymol. 

DOSAGE OF THE CHLOROFORM-CASTOR OIL MIXTURE 



Age 


Dosage 
c.c. 


Chloroform, 
Minims 


Castor Oil, 
c.c. 


From 6 to 7 years 

From 8 to 9 years 

From 10 to 11 years 

From 12 to 13 years 

From 14 to 15 years 

Over 15 and under 60.... 


6 
8 
12 
14 
16 
20 


11 

12 
15 
20 
25 
30 


14 

12 

8 

6 

4 



Kantor suggested the giving of oil of chenopodium 
by use of the intestinal tube. The tube is swallowed 
and the dose of chenopodium administered directly into 
the intestine. The oil of chenopodium is followed later 
by a large dose of warm solution of magnesium sul- 
phate. This treatment assures that the oil reaches the 
point of lodgment of the worms directly. 

Possible undesired symptoms from wormseed oil are 
drowsiness and depression. Such symptoms occurring, 
rapid purging should be caused by a saline cathartic, 
and such stimulants as hot coffee or caffein should be 
given. 

Roth has reported symptoms of deafness occurring 
in a number of patients following treatment with oil of 
chenopodium. This usually cleared up within a brief 
period of time, but in two cases persisted longer than 
one year. This fact should be borne in mind when oil 
of chenopodium is administered. 



316 TAPE WORM 

TAPEWORM 

Treatment to eradicate a tapeworm is based on 
several factors which, though simple, are fundamental. 
The treatment should be grounded on a knowledge of 
the worm, its pathology and method of existence. 

The diagnosis of the presence of any of the tape- 
worms in the bowel must be finally settled by the find- 
ing of the organism in the stools. However, other 
phenomena such as indefinite pains, a sense of disten- 
tion, ravenous hunger, etc., are not unusual. 

Before administering the anthelmintic several days 
should be devoted to the preparation of the bowel. 
The patient should take only a light liquid diet and 
should gradually cleanse the bowel by the use of the 
following prescription : 

Gm. or C.c. 

IJ Magnesii sulphatis 60| 5 ii 

Spiritus chloroformi 151 or AS iii 

Aquae q. s. ad 200| flSvi . 

M. Sig. : A tablespoonful, in water, three times a day, an 
hour before meals. 

An enema of soap and water may be given at night. 
This treatment removes solid fecal matter from the 
bowel as well as any adherent mucus coating which 
may be present. The night before the final treatment 
is to be administered the patient is given a final 
cleansing dose, perhaps two tablespoonfuls of the 
above mixture, and he then takes no food and but little 
liquids. The next morning after the bowels have 
moved male fern may be given as follows : 

Gm. 

H Oleoresinae aspidii 4| or 3i 

Fac capsulas, 8. 

Sig.: Four capsules, with half a glass of hot water at 9 
a. m., and four capsules, with hot water, at 10 a. m. [Impor- 
tant: Before taking the' above capsules each one should be 
uncapped.] 

At 12 o'clock three tablespoonfuls of the magnesium 
sulphate mixture should be taken, to insure the rapid 
passage of the male fern through the intestine lest too 
much absorption take place. 

During the morning no nutrition should be taken 
other than black coffee, clear tea, or bouillon. 



ROUND WORM 317 

Except when momentarily otherwise engaged, the 
patient should be in bed, and should stay in bed the 
remainder of the day. For unavoidable faintness 
coffee may be administered at any time, or a hypo- 
dermatic injection of strychnin may be given. After 1 
o'clock any food may be given the patient that he 
desires. 

During the three or four hours of this active treat- 
ment, viz., from 10 a.m. to 1. or 2 p.m., the physician 
should remain with the patient, or a thoroughly trained 
nurse should be in attendance. 

The stools should all be passed into receptacles 
where they can be thoroughly strained afterward, in 
order that the parasite's head may be sought, and if 
the above treatment is carried out it will generally 
be found. 

Pomegranate has been highly lauded by various 
physicians as an efficient anthelmintic in these cases. 
It is best given, after thoroughly cleansing the patient's 
bowel as has been described, in the form of a fresh 
infusion. Three ounces of the fresh bark are macer- 
ated in twelve ounces of water for a half day and the 
infusion then boiled down one half. This quantity 
is taken within an hour, in several doses, and followed 
within an hour or two by castor oil. 

Pomegranate may cause dizziness and extreme 
nausea when given in this form. As alternative an 
alkaloid derived from the bark — pelleterin tannate — 
is sometimes used. The dose is from 3 to 6 grains, 
and should be given fasting, mixed with a little water. 
A glass of water should be taken a little after its 
administration and an hour afterward a cathartic. 

Other vermifuges include turpentine, kousso, pump- 
kin seed and thymol. 

ASCARIS LUMBRICOIDES: ROUND WORM 

The round worm is a common parasite, often very 
difficult to diagnose. The symptoms are indefinite and 
include vague colicky pains, foul breath, itching at 
the nose, etc. The common source of infection is 
water or food. The finding of the worm in the feces 
is the final proof of its existence. It is of reddish 



318 PIN WORM 

brown color, about %-inch in diameter. The male 
varies in length from 4 to 8 inches, the female from 
6 to 12 inches. Though the intestinal tract is the nor- 
mal habitat the worms wander, and they have been 
found in the larynx, nose, Eustachian tube, tonsil and 
other contiguous structures. 

TREATMENT 

The diagnosis having been confirmed, treatment 
should be begun by administering laxatives at night 
to cleanse the bowel. Santonin is a favorite vermifuge 
in these cases, but many cases of poisoning have fol- 
lowed its use and it should be given with caution. The 
dose is 1 to 2 grains. The drug may be administered 
in the following form: 

Gm. or Cc. 

IJ Santonini 30 gr. v 

Hydrargyri chloridi mitis.... 20 or gr. iii 

Sacchari lactis 3 gr. xlv 

M. et fac chartulas 10. 

Sig. : A powder, in water, every hour for three doses. 

Thymol has been used with good results in these 
cases and wormseed oil (oleum chenopodii), an Amer- 
ican product, has given good results. The dosage of 
the latter may be five drops on a lump of sugar and 
this may be repeated and followed by a cathartic. 

OXYURIS VERMICULARIS: PIN WORMS 

This worm varies in length from 1/5-inch for the 
male to 2/5-inch for the female. The former has 
a blunt tail, curved upward, the female a pointed 
drawn-out tail. The most common symptom is itching 
about the anus, caused by boring movements of the 
female in depositing eggs in the rectum. The worm's 
chief habitat is the bowel from the jejunum to the 
anus. It is believed that the source of infection is 
the swallowing of ripe eggs in drinking water or food. 
The treatment consists in removing the worms by 
frequent washing of the region infected. Internally 
salts, such as magnesium or sodium sulphate, may 
be given, or large doses of calomel. 



PIN WORM 319 

To dislodge the worms from the rectum enemata 
should be given. Among various enemata which have 
been recommended are decoctions of quassia — an 
ounce of quassia chips in a pint and a half of water 
boiled down to a pint and strained; lime water; salt 
water; glycerin and water; turpentine — 1 dram to a 
pint of soap and water, etc. 

For local itching and abrasion such ointments as 
the official unguentum phenolis (3 per cent.) or some 
mild sulphur ointment may be employed. 



DISEASES OF THE KIDNEY 



PYELITIS 

The causes of infection in the kidney, as elsewhere 
in the body, may be stated as a lowered resistance 
of the tissue and an organism capable of infecting 
the kidney, coming usually from a focus elsewhere 
in the body. Barber and Draper have shown that 
ascending infection by the ureters seldom if ever 
occurs as long as the peristalsis of the ureters is unim- 
paired and the ureterovesical valves maintain their 
integrity. Most infections are therefore probably 
hematogenous. The large number of such infections 
occurring in girls is evidence, however, that the 
condition is quite frequently a direct, ascending infec- 
tion. Among the factors lowering the resistance of the 
kidney tissue, kidney stone is perhaps the most com- 
mon cause, others being traumatism, urinary obstruc- 
tion, displacement, etc. The pyelitis of pregnancy 
arises from pressure of the gravid uterus which may 
mechanically obstruct the ureters. Not infrequently 
the pyelitis is a complication of such acute infectious 
fevers as typhoid and pneumonia. Among the various 
focal infections which may bear an etiologic relation- 
ship to pyelitis are tonsillitis, alveolar abscesses, and 
infections of the accessory nasal sinuses, but cholecys- 
titis and intestinal infection are very frequent causes. 

The organisms producing pyelitis are colon bacilli, 
tubercle bacilli, staphylococci, streptococci, gonococci, 
typhoid bacilli, paratyphoid bacilli and pneumococci. 
These infections occur rapidly, are usually acute and 
persistent, may cause multiple abscesses, and may 
destroy the kidney and often the life of the patient. 
The early diagnosis must be made by exclusion, as the 
symptoms are essentially abdominal and may simulate 
other troubles like appendicitis, liver disorder, etc. 
The most prominent symptom in kidney suppuration 
besides fever is marked tenderness at the costovertebral 
angle, which is always present. The urine does not 



TREATMENT OF PYELITIS 321 

always show the micro-organism but in advanced or 
serious cases it will contain leukocytes as shown by 
a milky appearance; and there will be a leukocytosis, 
usually not over 25,000. Polyuria, especially at night, 
is a fairly common symptom in children. A severe chill 
usually means a high grade of infection. Staphylo- 
cocci and streptococci nephritic attacks are most fre- 
quent and have been observed following boils, tonsillitis, 
acute osteomyelitis, felon, ulcerations about the rectum 
and contagious impetigo. 

TREATMENT 

Primarily in the treatment of pyelitis the cause must 
be sought, that is, the focus, the nephrolithiasis, or 
cystitis, and this condition treated primarily. The 
patient should be kept absolutely at rest in bed on a soft, 
meat-free diet. The liquid intake should be sufficient 
to cause the patient to pass from two to three quarts of 
urine daily and thus flush the kidneys out thoroughly. 
The bowels should be kept moving freely and regu- 
larly. The medicinal treatment of pyelitis depends on 
whether the urine is acid or alkaline. If the patient 
is troubled by frequency of and distress on urination 
it is best to render the urine alkaline as it is then less 
irritating. The alkalinization of the urine is further- 
more an excellent method of treating the pyelitis, for 
the bacteria causing the pyelitis do not thrive in an 
alkaline medium. The alkalinization of the urine may 
be accomplished by the use of alkaline drinking waters, 
or fruit juices, of acetates, citrates or carbonates. The 
carbonates are the most effective, but are not always 
well tolerated by the stomach, in which case some of 
the other salts may be tried. It is best to use this 
method of treatment until the' bladder irritability has 
disappeared and then allow the urine to become acid 
and to prescribe hexamethylenamin for a few days 
until the bladder becomes irritable again, when the 
alkaline treatment is resumed. Potassium citrate and 
sodium citrate are the preparations most commonly 
used. Smith (Amer. Jour. Med. Sc. 1, 392, 1918) 
recommends 15 to 20 grains every two hours during 
the day and perhaps every four hours during the night, 



322 RENAL TUBERCULOSIS 

as may be required, to keep the urine alkaline for from 
ten days to two weeks after the symptoms have dis- 
appeared. Other drugs, such as salol, methylene blue 
and the oil of sandalwood also are used in the treat- 
ment of this condition. 

Relief is frequently afforded to patients with pyelitis 
by ureteral catheterization and pelvic lavage with 
weak solutions of silver nitrate (1 per cent.), mercuric 
oxycyanid from 1 : 10,000 to 1 : 5,000, or formaldehyd 
( 1 : 20,000) . Argyrol, collargol and other silver prep- 
arations have also been mentioned for this purpose. 
It should be remembered, however, that ureteral cath- 
eterization requires expert technic. 

In children, in whom the disorder is common, the 
majority of cases will yield to alkaline treatment and 
sweat baths. Vaccines are rarely useful in pyelitis. 
Autogenous vaccines may be tried, but they must be 
used with great caution, as violent reactions may be 
produced. 

If a purulent kidney does not improve rapidly, if 
the patient is becoming debilitated, or if the kidney 
is found enlarged and examination of the urine from 
this kidney shows that the kidney structure is diseased, 
temporizing should cease, and the kidney should be 
removed, unless the other kidney is so diseased as to 
render the operative danger very great. 

RENAL TUBERCULOSIS 

Renal* tuberculosis is a progressive infection, slow 
in its development, often remittent and probably incur- 
able by medical means. It may appear in the miliary 
form as a part of a general tuberculosis. There also 
exists a chronic parenchymatous nephritis occurring 
in the later stages of lung tuberculosis. According 
to some writers, there is an interstitial tuberculous 
nephritis. Most important, perhaps, is the type of 
minute focal infections tending to coalesce almost 
invariably unilateral at first and occurring in persons 
not affected with active tuberculosis. This is the 
form usually meant by the term renal tuberculosis. 
There are no diagnostic symptoms for the early stages. 
The first is vesical irritability, followed later by 



ALBUMINURIA 323 

albuminuria and perhaps hematuria. It is apt to be 
confused by the practitioner with renal stone, though 
that is a much rarer condition. Pyelography is an 
important aid to diagnosis. Pus in the urine is not 
long delayed and with it the tubercle bacillus appears. 
The blood stream is the mode of invasion except in 
very rare cases. One kidney is first affected in most 
cases, but the other kidney may later become involved. 
There is one way of treating the patient, namely, by 
nephrectomy, which gives immediate relief in 75 per 
cent, of cases, and permanent cures in perhaps 50 
per cent., if the operation is early performed. 

ALBUMINURIA 

The appearance of albumin in the urine may be due 
to any one or more of many different causes. These 
may be classed as follows : 

1. A symptom of nephritis. 
2.' Accidental albuminuria: 

(a) Dietary (alimentary). 

(b) Chilling of the body. 

(c) Unexplained (frequently focal infection). 

3. Incidental albuminuria : 

(a) Cold baths. 

(b) Menstruation. 

(c) Athletics or other physical strain. 

(d) Cardiac weakness. 

(e) Irritation in some part of the urinary tract. 
(/) Hypertension. 

(g) Ether or other anesthesia. 

4. Orthostatic (lordotic, cyclic, adolescent). 

Albumin in the urine comes either from the kidneys 
or from the urinary tract. If it is the result of a 
localized irritation, inflammation or hemorrhage, there 
are more leukocytes present in the urinary sediment 
than in ordinary albuminuria. In case of hemorrhage 
erythrocytes will be found. Albuminuria caused by 
nephritis will be discussed under that head. When 
albuminuria is caused by any of the conditions listed 
as accidental or incidental the prevention and treat- 
ment is self-evident. Athletes and others performing 
severe muscular exercise not infrequently give evidence 



324 TREATMENT OF ALBUMINURIA 

of a temporary albuminuria. Bornstein and Lippmann 
(Ztschr. f. Klin. Med., 86, 345, 1918) noted a striking 
parallelism in such cases between the excretion of 
albumen and the acidity of the urine. The frequency 
of cylindroids in the urine also seemed to be related 
to the concentration of urinary acid. These phenomena 
— albuminuria and cylindroids — were checked by 
administration of alkali during the exercise or working 
period. 

Orthostatic albuminuria is shown to be related to 
lordosis which produces a passive hyperemia of the 
kidneys with leakage of albumin. It should be limited 
to that albuminuria without casts which occurs after 
standing or moving about, and which disappears with 
a reclining position. It may also be due to an insuffi- 
ciency of the kidney circulation, possibly congenital, 
with or without lordosis. It may also be due to cer- 
tain occupations which throw an especially large 
amount of work on the kidneys, resulting in passive 
congestion. Before an albuminuria is considered a 
simple albumin leak, all suspicion of more serious con- 
ditions of the kidneys must be eliminated by examina- 
tions of the urine under varying conditions. Casts 
must be absent, and there must be no cardiac hyper- 
trophy or other symptoms which would show that the 
kidneys are suffering from localized or general inflam- 
mation. 

The results of a urine examination on first rising in 
the morning and again in the latter part of the after- 
noon will show whether the condition is an orthostatic 
albuminuria. Dietary tests and exercise tests will also 
show the limitations of the kidneys and their ability to 
sustain increased work. 

TREATMENT 

Strenuous exercise should be forbidden, and the 
body functions should be regulated in an effort to 
secure as near an approach to normal as possible. A 
great deal of rest should be enforced. Anemia should 
be looked for and treated. The condition of the heart 
should be studied and regulated. The bowels should 
be regulated and the intestinal condition kept normal 



ACUTE NEPHRITIS 325 

by the use of a carefully chosen diet. Sea bathing and 
cold bathing should be prohibited. A warm bath may 
be allowed regularly to aid elimination through the 
skin. Alkalis may be administered experimentally and 
their effect on the urine findings carefully noted. 

ACUTE NEPHRITIS 

Acute nephritis arises as a result of injury to renal 
parenchyma due to bacterial infection or chemical 
toxins. To the first of these belong the acute nephritis 
of scarlet fever and the other acute infections, though 
there may be a toxic element in addition. The classical 
example of the infectious type of acute nephritis is 
that which follows an acute tonsillitis or sinusitis. As 
examples of the toxic type, we have the cases follow- 
ing extensive burns and poisoning with such sub- 
stances as turpentine, cantharides, phenol, the sali- 
cylates, potassium chlorate, iodoform, mineral acids, 
arsenic, phosphorus, mercury and lead. The acute 
nephritis of pregnancy is also probably in part of 
toxic origin. Alcoholism is of itself probably not a 
cause of nephritis, but the exposure that so often 
accompanies excessive use of alcohol may give rise 
to an acute infection which is the cause of the 
nephritis. Bacteria are present in nearly all types. 

As to prognosis, the acute nephritis may clear up 
entirely, it may become chronic, or it may end fatally 
due to uremia, anasarca, or to a pneumonia or other 
terminal infection. In some cases there results a per- 
manent albuminuria which is not, however, accom- 
panied by symptoms of renal disease. In fact, in these 
cases there is no impairment of renal function as shown 
by such functional tests as the phenolsulphonephthalein 
test. The cause of this albuminuria is probably a 
permanent cicatrization in a portion of one or both 
kidneys which is, however, not sufficient to impair the 
renal function. 

There are two rather diametrically opposed methods 
of treating acute nephritis, one based wholly on clinical 
experience and the other principally on the experi- 
mental work of Martin H. Fischer. 



326 TREATMENT OF ACUTE NEPHRITIS 
FISCHER TREATMENT 

Fischer in his experimental work has shown that 
acidosis will cause edema and albuminuria and that 
this edema and albuminuria can be overcome by over- 
coming the acidosis with alkalies. He argues that in 
nephritis we have conditions similar to those that he 
has experimentally produced by acidosis and over- 
come by the use of alkalies. Further, he has shown 
that by using sodium chlorid, a smaller amount of 
alkali is needed to overcome the acidosis and the 
resulting edema. He has outlined a treatment for 
nephritis based on this experimental work which in 
many cases seems to produce better results than any 
other treatment. He recommends that this hypertonic 
solution (sodium chlorid 14 grams, sodium carbonate 
10 grams and water 1,000 c.c.) be given per rectum; 
this is best given by the drop method and, unless the 
patient is becoming uremic, 500 c.c. at a time twice 
a day. If the patient is showing symptoms of impend- 
ing uremia 1,000 c.c. may be given per rectum or even 
intravenously. In giving the solution intravenously 
care must be taken that none of the solution enters 
the tissues as the hypertonic solution may cause a 
slough. The best method of giving it intravenously is 
through a needle into one of the veins of the forearm, 
such as the median basilic vein ; the solution should 
enter slowly, so that it may be well mixed with blood. 
Fischer's directions should be followed in preparing 
the solution for intravenous use. In addition to the 
above intravenous or rectal medication, he recom- 
mends giving alkalies and sodium chlorid by mouth. 
The alkalies may be given in water or in fruit juices. 
The liquid intake is not limited, but all liquids should 
be isotonic or hypertonic so as not to overcome the 
effect of the solution given per rectum. The diet is 
composed of soft foods which are heavily salted. The 
patient should be kept at rest in bed until well on the 
road to recovery and then allowed up a little more 
each day. The bowels should be kept moving freely 
by the use of salines. The total liquid intake and 
output must be accurately measured to make sure the 
edema is lessened. 



TREATMENT OF ACUTE NEPHRITIS 327 

GENERAL TREATMENT 

The following method of treatment is based on clin- 
ical experience and is in many ways opposed to 
Fischer's method. 

The patient should be put to bed in a warm, well 
ventilated room. All irritant drugs should be avoided ; 
cold applications should be avoided and also all chilling 
of the body. Baths should be taken in warm or hot 
water. Meat and meat proteins should be avoided as 
soon as albumin is found in the urine and the diet 
should be restricted to milk, thin gruels, barley water, 
etc. If possible the diet should be very free of salt. 
It is generally considered advisable because of the 
edema to restrict the water intake, but if the diet is 
salt free a moderate amount of water may be allowed. 
A refreshing drink may be prepared from a teaspoon- 
ful of cream of tartar in a pint of boiling water to 
which is added the juice of a lemon and a little sugar. 

If the patient's stomach is disturbed, a short starva- 
tion period is advisable. Liberal quantities of hot 
water may be given to relieve the vomiting, and if this 
is not sufficient, several 1 gm. doses of bismuth sub- 
carbonate and sodium bicarbonate should be given 
every three hours until relief ensues. 

To promote elimination the body should be kept 
quite warm and hot sponge baths given. Warm appli- 
cations may be applied to the kidney region. A few 
grains of calomel, or a saline purgative should be given 
to free the intestinal canal of toxic substances. In 
children rhubarb or cascara sagrada may be used. 
Enemas may be substituted for the cathartics. Diu- 
retics should not be given with the exception of water, 
to which sodium citrate or orange or lemon juice may 
be added. 

As has been stated the patient should be kept physi- 
cally and mentally at rest. If he is restless and can- 
not sleep a dose or two of chloral or of a bromid may 
be given. It is well to avoid the synthetic drugs 
because of their irritant effect on the kidney. 

Warm applications to the kidney region will aid in 
allaying the inflammation and to hasten the stage of 
resolution. These applications may be applied as hot 
alcohol and water fomentations bound close to the back 



328 CHRONIC NEPHRITIS 

by a bandage around the abdomen, kept warm by a hot 
water bag and changed as soon as cool; by the old 
fashioned flaxseed poultice ; by an electric heat pad, or 
by any other simple method. 

Under good treatment the albumin and casts usually 
disappear in from five to six weeks. During conval- 
escence the diet is gradually increased, a little salt 
being given from time to time. The patient may be 
given bread, rice, more cereals, potatoes, less milk and 
no meat. Small doses of iron (tincture of ferric 
chlorid, 5 drops three times a day) may be given in 
orangeade or lemonade. Saccharated ferric oxid, 3 to 
5 grains, may be given in tablet form. Eggs, vege- 
tables and fruit are gradually added to the diet and 
then after some weeks of a normal output of urine 
meats in small quantities may be tried. 

The signs of uremia are eyeblurs, possibly retinal 
changes, severe headache, momentary losses of con- 
sciousness, twitching of the muscles, cramps and even- 
tually convulsions and coma. The treatment of uremia 
will be discussed in a separate article. 

Treatment of acute nephritis by nephrotomy or by 
renal decapsulation has been practiced by some, espe- 
cially in those cases in which there is an abundance of 
lumbar pain and not very severe urinary symptoms. 
These operations have in some cases caused relief of 
symptoms, but should be tried as a last resort. The 
resulting scar tissue as it contracts may of itself 
aggravate conditions, especially if a chronic interstitial 
nephritis should ensue. 

As many cases of acute nephritis are due to bacterial 
infections the question of the use of vaccines arises. 
Vaccines as yet have not proved to be of an^ 
assistance in the treatment of nephritis in the acute, 
subacute or chronic stages. 

CHRONIC NEPHRITIS 

Chronic nephritis, Bright's disease, or as it is some- 
times called, cardio-vascular-renal disease, is increas- 
ing in frequency in this country, therefore its prophy- 
lactic treatment is very important. 

Patients suffering from this disease usually first con- 
sult a physician on account of the symptoms that are 
usually associated with high blood pressure. In 



TREATMENT OF CHRONIC NEPHRITIS 329 

some of the cases there is a history of a previous 
acute nephritis, of acute inflammatory rheumatism, 
there may be an old heart lesion or some other point 
in the history that makes the solving of the problem 
relatively simple. In the majority of the cases, how- 
ever, this history is not found and a physical exam- 
ination reveals nothing but a slightly enlarged heart and 
a slight edema of the feet. Urinalysis may reveal 
nothing, but on repeated examinations the urine will 
be found to be of low specific gravity and occasionally 
to contain casts and a trace of albumin. The blood 
pressure will be found to range from 170 to 200. In 
these cases a careful search for a chronic focus of 
infection sometimes reveals trouble in the tonsils, 
teeth, sinuses,- or gallbladder. All foci of infection 
should be removed, if possible. 

SYMPTOMS 

The general symptoms of chronic nephritis may 
include in addition to the characteristic changes in the 
urine, headache, indigestion, diarrhea or constipation, 
mental apathy or irritability, insomnia, dyspnea, edema, 
intermittent eye and ear disturbances, enlargement of 
the heart, high blood pressure, neuralgias, anemia, and 
retinal changes. 

TREATMENT 

The diet selected for chronic nephritics should be 
based on the excretory ability of the kidneys, the non- 
protein nitrogen content of the blood, the condition of 
the heart, the blood pressure, the state of the digestion, 
the weight of the patient and the physical and mental 
work required of him. The diet should be varied 
quite frequently. It is well for the patient to have 
nothing but skimmed milk one day in the week. It has 
not been shown that fresh fish, poultry and meat, 
except kidneys, sweetbreads, liver and shad roe (rich 
in purins), are any more harmful to the nephritic 
patient than are the vegetable proteins such as nuts, 
peas, beans and oatmeal, though some patients may 
tolerate these better. 

In the cases in which there is an old organic heart 
trouble this must be treated primarily, and as the 
heart condition improves so does the kidney trouble. 



330 TREATMENT OF CHRONIC NEPHRITIS 

The best treatment for these cases is rest in bed on 
restricted liquids and a soft, meat-free, salt-free diet. 
In the more severe cases the Karell management is 
efficacious. The Karell treatment consists of rest in 
bed and a light diet of milk and eggs. The fluid is 
limited to 1% pints per day. At first this is given, for 
two or three days, as milk only, 6 to 7 ounces at 
8 a. m., and 4 to 8 p. m. This is the most trying part 
of the method. Then 1 &gg is given at 10 a. m., and 
a biscuit at 6 p. m. for two days. Then 2 eggs 
with bread, and a little minced meat are allowed. In 
twelve days the patient returns to a careful ordinary 
diet, the fluid being still kept down to iy 2 pints, but 
not necessarily milk only. This method is said to be 
indicated for weak hearts for which digitalis is less 
appropriate. About the third day diuresis sets in for 
a short time, the dyspnea is relieved, the pulse im- 
proves and the edema subsides. Elimination through 
the gastro-intestinal tract should be promoted by the 
use of calomel (3 gr.) at night and salines in the 
morning. If the patient is showing signs of intoxica- 
tion, and is strong enough, hot air sweats may be bene- 
ficial. Venesection may also be indicated in such cases 
and, by relieving the heart and removing toxins, often 
causes marked improvement. The same management 
is applicable to the cases in which the kidney is the 
most affected organ. 

A most important item in the treatment of chronic 
nephritis is the preservation of cardiac compensation. 
The high blood pressure and cardiac hypertrophy of 
chronic nephritis constitute a compensatory mechan- 
ism enabling the kidneys to maintain adequate func- 
tion. They consequently are essential to the preserva- 
tion of life and should be protected by every hygienic 
and dietetic safeguard. High blood pressure should 
not be made the object of direct therapeutic attack. 
Nitrites should be reserved for emergency use to com- 
bat such developments as angina, cardiac asthma, etc. 
The appearance of dropsy in primary chronic nephritis 
almost invariably signifies the advent of cardiac fail- 
ure. At this stage digitalis becomes the mainstay of 
treatment and should not be withheld because the 



TREATMENT OF CHRONIC NEPHRITIS 331 

blood pressure is high, as it acts just as well, or even 
better, with a high blood pressure as with a falling 
pressure. 

In the cases that are primarily cardiac the use of 
caffein, digitalis, strophanthus and the other cardiac 
tonics is of great value. The use of theobromin and 
other drugs, the action of which is essentially diuretic, 
should be guarded, as in many cases of chronic renal 
disease they do not increase the output of urine and 
act rather as a poison to the system. 

In certain cases of chronic nephritis in which there 
is considerable edema without dilatation of the heart 
the Fischer treatment, as described under acute nephri- 
tis, produces excellent results, but on the whole it 
does not seem to be as efficacious in the chronic as in 
the acute nephritides. 

For the control of the edema Epstein has outlined 
a diet to increase the protein content of the blood. 
Substances rich in protein are selected and a total of 
120 to 240 gm. of protein supplied daily. This, it is 
argued, helps the blood to regain its osmotic power. 

ARTERIOSCLEROTIC TYPE 

Another form of chronic nephritis that must be 
considered is that caused by general arteriosclerosis. 
In this form there are two causes for the trouble, 
namely, the injury to the kidney parenchyma from 
the altered blood supply to the kidneys and the toxemia 
arising from the altered metabolism throughout the 
body which is due to impairment of the circulation 
from the arteriosclerosis. In this form the treatment 
must necessarily be purely palliative, as the cause can 
not be removed. These cases are usually weak, anemic 
and poorly nourished and consequently the sweats and 
venesection cannot be used. The Karell management 
is the best to use in severe cases of this type, but 
ordinarily restriction of liquids to one quart or so, a 
meat-free diet and free catharsis suffices to keep these 
patients comfortable. In these cases diuretics and car- 
diac stimulants must be used with great care and in 
many of them are contraindicated. 



332 MASSAGE IN NEPHRITIS 

In those cases of nephritis in which there is amyloid- 
osis the treatment should aim primarily at the causa- 
tive condition, as the kidney condition is secondary 
to it. 

CARDIOVASCULAR RENAL DISEASE WITH HIGH BLOOD 
PRESSURE 

As to the treatment of the cases of long standing 
cardio-vascular-renal disease that are to all appear- 
ances in excellent health, but have a constant high 
blood-pressure and much of the time have albumin 
or casts in the urine: Most of these cases may be 
kept very comfortable and the blood-pressure kept 
reasonably low if they will diet carefully and exercise 
only moderately. Such individuals should eat but 
little meat of any kind. Coffee, tea, alcohol, rich 
spiced foods and tobacco should not be used at all. 
The diet then should consist of fruits, cereals, veget- 
ables, eggs, milk, cream, butter, and in most cases 
a little meat once a day. Shell fish may be used in 
moderation. 

These patients may exercise moderately, and indeed 
it is best for them to get a definite amount of out-of- 
door exercise. Walking is the best form and for some 
golf in moderation. Whatever form of exercise is 
taken, it should be begun gradually and increased 
slowly. While this is being done the patient should 
be frequently examined by the physician to make 
sure that he is not overdoing. 

MASSAGE AND BATHS 

The massage and bath treatment of nephritis, when 
regulated by a physician who is in close touch with the 
patient's general condition, given at many places 
abroad and in this country, is excellent. However, 
unless controlled by a physician, such treatment may 
do a great deal of harm. Massage is only a form of 
exercise and if overdone may do as much harm as too 
much exercise of any other sort. Baths are quite 
enervating and fatiguing even to a healthy individual 
who is not accustomed to them, and so to the nephritic 
with his lowered vitality they may be a source of great 
danger. 



UREMIA 333 



CLIMATE 



When it is possible, patients suffering from chronic 
nephritis should spend as much time as possible in 
warm climates, as warm weather promotes elimination 
through the skin. Furthermore, by causing a super- 
ficial vasoconstriction, cold tends to increase the ten- 
sion in the deeper vessels and so increase the possi- 
bility of cerebral hemorrhage or hemorrhage from 
other vessels. Angina pectoris, which may be a com- 
plicating factor in many of these cases of hyperarterial 
tension, often follows sudden exposure to cold. 

UREMIA 

When uremia is imminent premonitory symptoms 
occur, such as headache, fulness of the head, vertigo 
and blurring of vision, muscle twitching, muscle 
cramps, restlessness, insomnia or drowsiness and fre- 
quently nausea, vomiting and diarrhea. The blood 
pressure increases and the urine shows a decrease in 
the amount of solids excreted. Chilling, a high protein 
meal, extra muscular exercise, nervous or mental 
excitation, or anything which may suddenly increase 
metabolism and nitrogen waste may precipitate an 
attack. 

TREATMENT 

The diet in impending uremia should be the mini- 
mum diet, perhaps only as much as a pint of milk a 
day. The water intake should depend on the amount 
of water elimination, edema and dropsy. As the diet 
is increased considerable alkali and cereals may be 
given, to combat acidosis. 

In uremic patients there is a severe toxemia due to 
renal insufficiency. When the patient is quiet, the 
relief of the toxemia is the chief requirement except 
such supportive measures as may prove necessary. 
This toxemia has usually been treated by the promo- 
tion of elimination through the skin by sweats, 
through the intestines by free catharsis and rarely by 
venesection. The diuretics are generally of little use 
in treating these conditions. Fischer's solution admin- 
istered intravenously or per rectum has proved to 
be one of the best methods of promoting elimination 



334 CYSTINURIA 

through the kidneys in these cases ; the general symp- 
toms are also greatly relieved, even when sweating and 
venesection are not used. Some of the most striking 
results obtained by the use of Fischer's solution have 
been in cases in which there was insufficient excretion 
of urine and a consequent uremic condition with no 
clinically demonstrable anasarca. 

RESTLESSNESS 

In those cases of uremia in which the patient is 
extremely restless, and also in those in which there 
are convulsions, the eliminative treatment must be 
used, and in addition the patient must be quieted. 
In the first place the usual methods of restraining a 
patient in bed must be practiced; windows should be 
protected to prevent accidents; all instruments with 
which injury might be done to attendants or to the 
patient should be kept out of reach. Bromids may be 
given in enemas in doses of twenty to thirty grains 
in place of the salt of the Fischer's solution. If the 
patient will take them, they may be given by mouth. 
Chloral may also be administered either by mouth or 
per rectum. In the more severe cases it is necessary 
to use opiates and sometimes even chloroform to 
quiet the convulsions. 

VENESECTION 

If the blood pressure is very high, and apoplexy 
or sudden dilatation of the heart threatens, venesection 
should be done, as also in threatening convulsions or 
coma. 

CYSTINURIA 

Cystinuria may be classed among the rarities of 
medical practice. However, the perversion of metab- 
olism whereby cystin, one of the amino-avid frag- 
ments of the protein molecule, is not destroyed in the 
body as it is in a normal person, is not so uncommon as 
statistics might lead one to believe. As the metabolic 
disorder may exist for very long periods without 
revealing itself by any easily detected symptom 
other than the presence of the unutilized cystin in 
the urine, the discovery of the cases becomes more or 



INDICANURIA 335 

less fortuitous. Only when urinary concretions arise 
to direct attention to their cause, or when the presence 
of crystin is detected by chance in a routine examina- 
tion of the urine, does the anomaly come to the knowl- 
edge of those who are interested in its cause and 
treatment. 

From the point of view of the patient the chief prob- 
lem in connection with cystinuria is either to decrease 
the output of cystin or to increase its solubility in the 
urine — or both — with the aim of avoiding the impend- 
ing danger of calculi. The pronounced insolubility of 
cystin in urine of the usual reaction makes the pos- 
sibility of attacks of "kidney colic" and related conse- 
quences an ever-present one. It has long been known 
that the output of cystin can be decreased by a diminu- 
tion of the metabolism of its mother-substance, pro- 
tein. In the entire absence of any intake of albu- 
minous foods the urinary excretion of cystin is 
reduced to an endogenous level, represented in an 
illustrative case in literature by 78 mg. a day. 

Klemperer and Jacoby (Therap. der Gegenw., 1914, 
lv., p. 101) studied the results of alkali administra- 
tion in such a case. They found that the deposited 
cystin sediment promptly decreased in amount and 
soon completely disappeared from the urine following 
the daily ingestion of from 6 to 10 gm. of sodium 
bicarbonate. From the point of view of preventing 
the precipitation of cystin and consequent formation 
of calculi, this treatment was evidently successful. 
Incidentally, it further developed that even dissolved 
cystin entirely disappeared from the urine as the result 
of the alkali therapy. 

INDICANURIA 

Indicanuria is of comparatively frequent occurrence 
and is generally understood to mean that some protein 
putrefactive process is taking place in the ileum and 
colon with the production and absorption of indol 
and the excretion of indoxyl potassium sulphate (indi- 
can). Indican in the blood is not poisonous, but 
other products of decomposition and toxins absorbed 
from the intestines at the same time as the indol may 
produce symptoms of intoxication. Indol, skatol and 



336 TREATMENT OF INDICANURIA 

cresol with toxalbumin will frequently produce symp- 
toms of poisoning such as headache, restlessness, 
insomnia, gastro-intestinal indigestion, dryness of the 
skin or sometimes a profuse perspiration, eruptions, 
and even a rather severe kidney irritation. 

TREATMENT 

If it is found that the amount of indican excreted 
is increased the diet should be modified. Animal pro- 
teins should be removed for a time and there should 
be thorough purging. The cause of the condition 
should be sought. The bowels should be caused to 
move daily and regularly; colon washings may be 
given until the urine is practically indican free. Yeast 
or lactic acid bacilli may be administered, but it is 
doubtful that they exercise any very prolonged effect. 
Liquid petrolatum is now much used but it is a ques- 
tion whether it may not interfere with the secretions 
if given over long periods. Phenyl salicylate (salol) 
in a dose of 0.25 or 0.30 gm. in capsules, three times 
a day after meals, for a short period is often of benefit 
in preventing intestinal fermentation. Anemia is not 
rare accompanying chronic intestinal putrefaction. 
The weight of the patient should be noted carefully 
and the skin watched for the appearance of eruptions, 
dryness or profuse perspiration in order to regulate 
properly the food, drink and possible drug administra- 
tion which may be required. 



DISEASES OF METABOLISM 



DIABETES MELLITUS 
DEFINITION 

Diabetes has been defined as a "specific deficiency 
of the power of assimilating food." The generally 
accepted view, based on experimental evidence, refers 
the deficiency to a diminished functional capacity of 
the pancreatic islets. A person with a normally func- 
tionating pancreas may ingest a quantity of food con- 
siderably in excess of his energy requirement and 
completely assimilate all that is digested and absorbed, 
even though the greater part of the food may be carbo- 
hydrate. An average adult, performing light work, 
will ingest and metabolize from 300 to 500 gm. of car- 
bohydrate a day. With impaired pancreatic function, 
the organism becomes incapable of assimilating even 
such quantities of carbohydrate as are contained in a 
general mixed diet, that is to say, a diet sufficient to 
cover the energy requirement in which from one half 
to two thirds of the total caloric intake is in the form 
of carbohydrate. 

Where there is a deficiency of the power to assimi- 
late carbohydrates, glucose accumulates in the blood ; 
and when the concentration reaches a certain limit, 
the excess of glucose overflows through the kidneys. 
Thus, glycosuria constantly occurring in an individual 
whose food intake is within the limits mentioned 
above, is evidence of diminished pancreatic function 
of the specific type here considered — it is evidence of 
diabetes. 

Strictly speaking, this statement requires some modi- 
fication, for there are certain persons who pass sugar 
in the urine when the blood sugar concentration is 
normal or even below normal. The glycosuria in 
such cases seems to be due to an increased permea- 
bility of the kidney for glucose. This condition of 
"renal diabetes" is of infrequent occurrence; it is 
unaccompanied by the characteristic symptoms of dia- 



338 DIAGNOSIS OF DIABETES 

betes, such as polyuria, and polydipsia; the amounts 
of sugar excreted in the urine are seldom large, and 
bear but little relation to the carbohydrate intake. A 
positive diagnosis of the condition can be made only 
by demonstrating a normal or low blood sugar count 
coincident with glycosuria. 

If the food intake of a diabetic is diminished so as 
to come within his assimilative capacity, sugar excre- 
tion ceases. Absence of glycosuria is, therefore, not 
to be taken as evidence that diabetes is not present, 
unless the individual is on a full, mixed diet. 

For the detection of glucose in the urine a very 
satisfactory reagent is Benedict's (Jour Biol. Chem., 
1909, v. 485), modification of Fehling's solution, since 
it is very sensitive to glucose, but, unlike the original 
Fehling's solution, does not react with a number of 
normal and accidental urinary constituents. The reduc- 
tion test, if slight, should be confirmed by the fermen- 
tation test. 

In diabetes, there is a lowered functional capacity, 
not only for the assimilation of carbohydrate, but also 
for protein, since the latter food may yield a consider- 
able amount of its starch. 

In diabetes the metabolism of fats is affected since, 
as Naunyn has expressed it, "fats burn in the fire of 
carbohydrates." With failure to assimilate carbo- 
hydrates." With failure to assimilate carbohydrates 
the "fire" may be but a smoldering one, so that fats are 
incompletely burned with the formation of acetone, 
aceto-acetic acid, and beta-oxybutyric acid. The latter 
two substances, being acids, may, if produced in suffi- 
cient amounts, lead to a serious disturbance of the acid 
base equilibrium of the body, known as acidosis. It is 
acidosis that is presumably the cause of diabetic coma. 

OBJECT OF TREATMENT 

The object of the treatment of diabetes is to supply 
a diet that can be metabolized and that will not over- 
tax the weakened carbohydrate metabolism. Allen has 
aptly compared the functionally weak pancreas to a 
"weak" stomach. If the latter, with frequent rests, is 



THE ALLEN TREATMENT 339 

supplied with food of such quality and such quantity as 
can be readily digested, it may functionate satisfacto- 
rily, and may even be able to digest larger and larger 
amounts of food, although it will never become a 
"strong" stomach. Continued dietary insults, on the 
other hand, would further weaken the organ. The 
same holds true for the functionally weakened pan- 
creas; it may be able to provide for the assimilation 
of a certain amount of food, but if overwhelmed with 
an amount in excess of its capacity, a progressive 
diminution in capacity results. A weak stomach if 
overtaxed usually gives warning by discomfort; an 
overtaxed pancreas gives no such warning. 

THE ALLEN TREATMENT 

The diabetic who constantly indulges in food in 
excess of his assimilative capacity invariably becomes 
progressively worse; hence the conception has arisen 
that diabetes is characterized by an inherent downward 
tendency. As a matter of fact, practically every dia- 
betic has some tolerance for food, and the tolerance is 
usually sufficient to allow for a great enough food 
intake to cover the basal energy requirements. With 
proper treatment, it is possible to maintain or even to 
increase this tolerance. This is the underlying prin- 
ciple of the modern treatment of diabetes as formu- 
lated by Dr. Frederick M. Allen. On the basis of 
animal experiments and carefully controlled clinical 
observations, he has proposed a system for the treat- 
ment of diabetes that incorporates those features of 
the older methods that are of proved value, but intro- 
duces, in addition, a number of features,- some of which 
are in direct opposition to the older teachings. 

This treatment may be briefly outlined as follows : 

1. A preliminary fast is taken until the urine is free 
from sugar. 

2. Following the fast, carbohydrate food is grad- 
ually added, at first in the form of green vegetables. 

3. Coincident with the addition of carbohydrate, or 
in place of it if the carbohydrate tolerance is very 
low, protein is added to the diet in small but gradually 



340 THE PRELIMINARY FAST 

increasing amounts until glycosuria occurs, or a suffi- 
cient amount of protein is taken to cover the basal 
requirement. 

4. Fats are added in small amounts during the time 
of addition of carbohydrates and protein. Subse- 
quently, a sufficient amount of fat is added to make up 
the fuel requirements of the body, provided this 
amount can be tolerated without the appearance of 
glycosuria or acidosis. 

5. Frequent urine examinations are made, either 
by the medical attendant or by the patient himself, and 
the appearance of glucose is taken as an indication for 
a fast of sufficient length to cause a cessation of the 
glycosuria. Feeding is subsequently begun with not 
more than one half of the carbohydrate contained in 
the diet at the time of the appearance of glycosuria. 
Subsequent carbohydrate increase is made very grad- 
ually. 

6. At intervals, the patient is fasted for a day or 
else takes a greatly restricted diet. 

7. Body fat is reduced to a minimum and the adult 
diabetic is not allowed to gain weight; children may 
gain, but the gain must not be adipose tissue. 

8. Active daily exercise carried to the point of 
healthy fatigue is advocated. 

THE PRELIMINARY FAST 

The object of the preliminary fast is to remove 
from the body the excess of unassimilated carbo- 
hydrates and to allow for a rest of the overtaxed 
pancreatic function. As a result of the fast and, 
indeed, during the fasting period, a proportionately 
larger amount of carbohydrate may be metabolized. 
Paradoxical as this may appear at first sight, it has 
been definitely proved by calorimetric observations on 
severe diabetics. With the removal of the unassimi- 
lated excess, the organism is better able to assimilate 
an amount of carbohydrate which it was previously 
unable to utilize. Before the fast is begun there should 
be two or three days of privation of all fats. 

During the fast, in trie majority of instances, there 
is a decreased production of the potentially harmful 



DURATION OF FAST 341 

aceto-acetic and beta-oxybutyric acids. This, presum- 
ably, is the result of the relative increase in carbohy- 
drate assimilation. 

The length of fast required before the urine becomes 
sugar free is usually less than five days ; exceptionally, 
it may be as long as eight or ten days. Water is 
allowed ad libitum, and tea or coffee in moderate 
amount if desired. No sugar or cream is allowed, 
though saccharin may be used for sweetening. A 
reasonable amount of clear meat broth may be taken 
after the second day of fasting. 

Alcohol, in the form of whisky, has been recom- 
mended, since it does not increase glycosuria, and in 
certain cases seems to inhibit the production of the 
acetone bodies. The amount of whisky given may be 
1 ounce three times daily. It may be given in black 
coffee. ■ Alcohol is not an essential, in the treatment, 
and should not be administered to patients in whom it 
produces such symptoms as burning in the throat, 
headache and nausea. 

DURATION OF FAST 

The great majority of diabetics may be fasted until 
the urine is sugar free, without the development of any 
untoward symptoms or complications. Exceptionally 
marked prostration, nausea, increasing drowsiness and 
deep breathing (acyanotic hyperpnea) may occur. 
These are symptoms referable to acidosis, and occur 
coincidently with alterations in the composition of the 
blood, alveolar air and urine. With the appearance 
of a severe and progressive acidosis, the fast must be 
terminated for the time being, and treatment directed 
against the acidosis. (This phase of the subject is 
discussed under the head of Acidosis.) After a 
period of restricted diet a subsequent fast usually 
results in a sugar-free urine without the development 
of acidosis. 

THE DIET 

Addition of Carbohydrates to the Diet. — When, as 
a result of the fast, the urine has been free from sugar 



342 



THE DIET IN DIABETES 



for twenty-four hours, feeding may be cautiously 
begun. All the food given must be weighed and its 
composition must be known approximately, at least. 
Unless this is done, no accurate idea of the food tol- 
erance or of its caloric value can be obtained, and 
subsequent treatment becomes of necessity a "hit-or- 
miss" affair, with the probabilities all in favor of its 
being a "miss/' Information as to the composition of 
the common foods may be obtained from various trea- 
tises on dietetics and food chemistry. 

The accompanying table, compiled by Joslin, con- 
tains in a compact form all the essential information. 
The figures, although only approximate, are sufficiently 
accurate. 

JOSLIN'S DIET TABLE 

Strict Diet— Meats, Fish, Broths, Gelatin, Eggs, Butter, Olive Oil, Coffee, 

Tea and Cracked Cocoa 

Foods Arranged Approximately According to Percentage of 

Carbohydrates 



Vegetables 



5 PerCent. 


10 Per Cent. 


15 Per Cent. 


20 Per Cent. 


Lettuce 


Onions 


Green peas 


Potatoes 


Spinach 


Squash 


Artichokes 


Shell beans 


Cauliflower 


Turnip 


Parsnips 


Baked beans 


Sauerkraut 


Carrots 


Canned lima 


Green corn 


String beans, 


Beets 


beans 


Boiled rice 


canned 


String beans 




Boiled maca- 


Celery 


Pumpkin 




roni 


Asparagus 


Kohlrabi 






Cucumbers 


Green peas, 






Brussels sprouts 


canned 






Sorrel 








Endive 








Dandelions 








Swiss chard 








Sea kale 








Tomatoes 








Rhubard 








Egg plant 








Leeks 








Beet greens 








Watercress 








Cabbage 








Radishes 








Pumpkin 








Kohlrabi 








Broccoli 








Vegetable marrow 








Artichokes, canned 








Mushrooms 








Okra 









THE DIET IN DIABETES 343 

Fruits 



Ripe olives (20 per 


Lemons 


Apples 


Plums 


cent, fat) 


Oranges 


Pears 


Bananas 


Grapefruit 


Cranberries 


Apricots 


Prunes 




Strawberries 


Blueberries 






Blackberries 


Cherries 






Gooseberries 


Currants 






Peaches 


Raspberries 






Pineapple 


Huckleberries 






Watermelon 







Nuts 



Butternuts 
Pignolias 



Brazil nuts 
Black walnuts 
Hickory 
Pecans 

Filberts 



5 Per Cent. 
Miscellaneous. — Unsweetened and 
unspiced pickles, clams, oysters, 
scallops, liver, fish roe 



Almonds 
Walnuts (Eng.) 
Beechnuts 
Pistachios 
Pinenuts 



Peanuts 



40 Per Cent, 
Chestnuts 



Reckon actually available carbo- 
hydrates in vegetables of 5 per 
cent, group as 3 per cent., of 10 
per cent, group as 6 per cent. 



Thirty gm. or 1 ounce, of each of the following contain approximately: 



Oatmeal, dry weight 

Meat (uncooked) 

Meat (cooked) 

Broth 

Potato 

Bacon (cooked) 

Cream, 40 per cent 

Cream, 20 per cent 

Milk...». 

Bread 

Butter. 

Egg (one) 

Brazil nuts 

Orange (one) 

Grapefruit (one) 

Vegetables, 5 and 10% groups 



Protein, 


Fat, 


Carbo- 


Gm. 


Gm. 


hydrates, 
Gm. 


5 


2 


20 


6 


3 





8 


5 





0.7 








1 





6 


5 


15 





1 


12 


1 


1 


6 


1 


1 


1 


1.5 


3 


0.5 


18 





25 





6 


6 





5 


20 


2 








10 








10 


0.5 





1 



Calo- 
ries 



120 
50 
75 
3 

30 
155 
120 



225 
75 

210 
40 
40 



1 gm. protein, 4 calories. 

1 gm. fat, 9 calories. 

6.25 gm. protein contain 1 gm. nitrogen. 
30 grams (gm.) or cubic centimeters (c.c), 1 ounce. 

A patient "at rest" requires from 25 to 30 calories per kilogram body 
weight. 

1 gm. carbohydrate, 4 calories. 

1 gm. alcohol, 7 calories. 

1 kilogram, 2.2 pounds. 



344 THE DIET IN DIABETES 

A convenient scale for weighing food is a mov- 
able dial spring balance. 

Feeding is begun with food containing but small 
amounts of carbohydrate and lesser amounts of pro- 
tein and fat. The most satisfactory diet to begin with 
is one composed exclusively of green vegetables of the 
"5 per cent, group" (see table). These vegetables, 
although they contain but little available nutriment, 
have a large bulk and serve to fill the stomach, thus 
allaying in some measure the pangs of hunger. The 
indigestible residue is valuable in preventing constipa- 
tion. From 150 to 200 gm. of the vegetables of this 
group are given the first day. Approximately 5 gm. of 
available carbohydrates are contained in this amount. 
If no glycosuria occurs, the diet on the second day 
may contain vegetables equivalent to five more grams 
of carbohydrate, and this increase is made daily until 
20 gm. of carbohydrate are given. Following this, 
5 gm. are added every other day until glycosuria 
occurs or the patient is receiving as much as 3 gm. of 
carbohydrate per kilogram of body weight in twenty- 
four hours (Joslin). After the first day or two carbo- 
hydrate may be given in the form of vegetables of the 
10 per cent, group, followed subsequently by those of 
the 15 and 20 per cent, groups. Fruits are then added, 
and ultimately, if glycosuria has not supervened, bread 
and oatmeal. 

Vegetables are best cooked by steaming in a double 
boiler, as in this way nothing is lost. 

Ordinary bread is but seldom included in the dietary 
of the diabetic. There are on the market a large 
number of brands of "gluten" and "diabetic" flour 
which contain relatively little carbohydrate and much 
protein. Bread made from such flour, provided the 
composition is accurately known, is satisfactory. These 
special brands of flour, however, are expensive and 
many are fraudulent. 

The patient's longing for bread may, in a measure, 
be satisfied by bran biscuits. These contain no 
carbohydrate and serve as a convenient vehicle for the 
administration of butter or other fats. The bulky 
residue fills the stomach and relieves constipation. 



THE DIET IN DIABETES 345 

The recipe used at the Rockefeller Institute Hospital is: 

Bran 60 gm. 

Salt % teaspoonful 

Agar agar, powdered 6 gm. 

Cold water 100 c.c. (% glass) 

Tie bran in cheese cloth and wash under cold water tap until water 
is clear. Mix agar agar in the water (cold) (100 c.c.) and bring to 
the point of boiling. Add to washed bran the salt and agar agar solu- 
tion (hot). Mold into three cakes. Place in pan and, when firm and 
cold, bake in moderate oven from forty-five to fifty minutes. 

The appearance of glucose in the urine means that 
the patient's assimilative limits have been exceeded, 
and a fast must be instituted until the gylcosuria 
ceases. Following the fast, the carbohydrate ration 
should be diminished by one half and not increased 
beyond this amount for some days, and then very 
cautiously. The amount should be kept well within the 
limit of tolerance previously determined for a con- 
siderable period of time. Subsequently, if there is 
reason to suppose the patient can assimilate more 
carbohydrate, the limit of tolerance may again be 
determined by gradual addition of carbohydrate, even 
to a point in excess. of the former tolerance. 

In severe cases some patients cannot assimilate 
even the small amount of carbohydrate contained in 
green vegetables, although they may still be able to 
assimilate minimal amounts of protein and fat. Such 
patients may be given at first green vegetables that 
have been cooked in three changes of water and the 
water discarded. Vegetables so prepared contain 
practically no carbohydrate. 

Addition of Protein to the, Diet. — In severe cases of 
diabetes, it is advisable to determine the protein toler- 
ance in essentially the same way that carbohydrate 
tolerance is determined, eggs and meat alone being fed 
in increasing amounts until glycosuria occurs. In most 
cases of diabetes, however, protein may, to advantage, 
gradually be added to the diet during the period of 
testing the carbohydrate tolerance. During the first 
week of green vegetable feeding, provided no glyco- 
suria occurs, two or three eggs may be given during 
the day. Lean meat is then added from day to day in 
amounts corresponding to 10 or 15 gm. of protein (see 
table) until the patient is receiving daily about 1 gm. 
of protein per kilogram of body weight, or if the car- 
bohydrate tolerance is zero, only 0.75 gm. Later, if 



346 THE DIET IN DIABETES 

desired, protein may be raised to 1.5 grams per kilo- 
gram of body weight (Joslin), provided, of course, 
this can be done without the development of gylco- 
suria. Children may to advantage be given as much 
as 2 gm. of protein per kilogram. 
' Addition of Fats to the Diet. — When the amount of 
protein fed has reached 1 gm. per kilogram of body 
weight, fats may be added to the diet in gradually 
increasing amounts (25 gm. a day) until the caloric 
requirement of from 25 to 40 calories per kilogram of 
body weight is covered by the total food intake. 
Patients who are exercising require a higher caloric 
intake than when resting, and growing children up to 
as much as 50 or 60 calories per kilogram, depending 
on the age. The caloric intake should eventually be 
such that a progressive loss of weight does not occur. 
On the other hand, the patient must not gain in weight, 
or, more correctly, he must not gain in adipose tissue, 
though muscular development is allowable. 

Fat, besides that obtained in the eggs and meat fed, 
may be supplied in the form of bacon, cream, olive oil 
or butter. If marked acetonuria appears, it is advis- 
able to substitute olive oil for butter and cream. 

Weekly Fast Days. — For a long time it has been 
recognized that days of partial or complete fasting are 
of benefit to the diabetic. Allen has incorporated this 
idea into his system of treatment, and advises frequent 
fast days. Joslin's rule is to fast all patients once a 
week whose tolerance for carbohydrates is less than 
20 gm. When the tolerance is between 20 and 50 gm., 
5 per cent, green vegetables and one half the usual 
quantity of protein and fat are allowed on the fast 
days; when the tolerance is between 50 and 100 gm.- 
of carbohydrates, the 10 and 15 per cent, vegetables 
are allowed as well. If the tolerance is more than 100 
gm. of carbohydrate, the carbohydrate intake is halved 
on the weekly fast days. 

Exercise — This forms a valuable adjunct in the 
treatment of diabetes. It serves to raise the carbohy- 
drate tolerance and to build up active protoplasmic 
tissue at the expense of fat. In addition, the patients 
who exercise feel better and take more interest in life. 



ACIDOSIS 347 

The appetite is increased, but the increase is not 
greater than the increased assimilative power. Allen 
advises active exercises for practically all diabetics. 
Strong patients may begin exercise during the prelimi- 
nary fasting period ; weaker ones, during the period of 
dieting. Exercise is especially advantageous immedi- 
ately following a meal containing carbohydrate. Short 
periods of vigorous exercise are preferable to long 
continued monotonous walks. The patient should stop 
just short of uncomfortable fatigue. In children, 
exercise is of especial benefit, as it aids in the building 
up of muscular tissue and favorably influences growth. 

Acidosis. — In the course of diabetes, large amounts 
of the "acetone bodies," namely, acetone, aceto-acetic 
acid and beta-oxybutyric acid may be produced. These 
substances, for the most part, are products of the 
incomplete combustion of fats, and appear when 
there is a disproportionately great metabolism of fat 
as compared with carbohydrate. For the complete 
combustion of fat, it seems essential that a certain 
amount of carbohydrate be simultaneously burned. 
Under the older methods of treatment the production 
of large amounts of the acetone bodies at some stage 
of the disease was usual, and, as a result, a large 
proportion of all diabetics, and especially younger 
patients, ultimately developed coma — presumably as 
a direct result of overproduction of the acetone bodies. 
By strict adherence to the rules of treatment already 
formulated, it is usually possible to reduce the produc- 
tion of acetone bodies to a minimum. 

For the detection of acetone bodies in the urine, 
two tests are in general use, the nitroprussid reaction 
(Legal, Arnold, Rothera) and the ferric chlorid reac- 
tion (Gerhardt). The nitroprussid test is a very deli- 
cate one for either acetone of aceto-acetic acid. The 
ferric chlorid test is a less delicate one and serves 
to detect aceto-acetic acid. Since amounts of aceto- 
acetic acid smaller than are required to give the ferric 
chlorid reaction are of no especial significance, there 
is, in general, no reason for using the more delicate 
nitroprussid test: If one of the acetone substances is 
present in the urine, all are present, and there is no 
indication for testing for more than one of them. The 



348 ACIDOSIS 

ferric chlorid test is carried out by adding to the urine 
a strong solution of ferric chlorid until no further 
precipitation of phosphates occurs; a purple color 
indicates the presence of aceto-acetic acid. Salicylates 
give a similar reaction, but the color may be obtained 
after the urine has been boiled for a few minutes, 
whereas aceto-acetic acid is destroyed by boiling. 

Of the acetone substances, acetone itself is an 
adventitious decomposition product of aceto-acetic acid, 
and is probably never formed in sufficient quantity to 
do harm. Aceto-acetic acid and beta-oxybutyric acid, 
however, are fairly strong acids, and for that reason 
are capable of doing much harm to the organism by 
the neutralization and removal of the available bases. 
Acids of one kind or another are always being pro- 
duced in the course of metabolism, and the body 
possesses an efficient mechanism whereby these acids 
may be neutralized or excreted. A slight excess in 
acid production, such as a few grams of beta-oxybu- 
tyric acid, can be completely compensated for. With a 
larger production of acids, especially if continued 
over a considerable time, the compensatory mechanism 
of the body may become overtaxed, with the result 
that an actual depletion of the alkali reserve of the 
body fluids and tissues occurs. Such a condition 
is known as acidosis. In diabetes, the appearance of 
acetone bodies in the urine signifies that the ideal result 
of treatment has not been attained, but it does not nec- 
essarily mean that acidosis is present. Qualitative tests 
alone on the urine are not sufficient either to confirm or 
to exclude acidosis, as a strong test may be obtained 
when no acidosis is present, and only a faint reaction 
at the height of the coma of acidosis. 

A high excretion of ammonia in a twenty-four hour 
specimen of urine is an indication of abnormal activity 
on the part of the defensive mechanism of the body, 
and is a warning signal. Among the symptoms of 
incipient acidosis are indefinite malaise, headache, 
slight nausea, neuralgic pains, etc. In other words, 
they are extremely variable. Certain symptoms, as 
increasing drowsiness and deep breathing of the "air 
hunger" type (acyanotic hyperpnea), may indicate to 
the skilled observer the onset of acidosis ; but for an 



ALVEOLAR AIR 349 

accurate qualitative idea of the degree of acidosis 
determinations on the alveolar air or blood must be 
made. 

Alveolar Air. — In acidosis, there is a diminished 
carbon dioxid tension in the alveolar air. The deter- 
mination of this tension is a simple bedside proce- 
dure. Marriott described a rapid clinical method for 
the purpose, for the details of which the reader is 
referred to the original paper {Jour. A.M. A., May 20, 
1916, p. 1594). It is important that the degree of 
acidosis be known, especially during the fasting period, 
since failure to recognize a progressive acidosis may 
result in serious or even fatal consequences. 

The C0 2 combining power of the blood plasma as 
determined by the Van Slyke method is probably the 
method of choice in determining degree of acidosis. 
This test can be easily performed in any good labora- 
tory. It requires special apparatus and a little more 
than ordinary technical skill. 

According to Stillman, diabetics may react in a 
number of ways to their preliminary fast, as regards the 
development of acidosis. Some show no significant 
acidosis either -before, during, or after the fasting 
period. Others, with a severe grade of acidosis exist- 
ing before the fast, improve during the first fast, or 
during the subsequent fasts. A third group shows a 
fairly constant, low grade acidosis, not especially 
influenced one way or the other by the fast, but often 
relieved by subsequent, frequently repeated fasts, 
alternating with periods of low diet. A fourth group 
develops increasing acidosis during the fast, which may 
even become of a sufficient degree to prove fatal. 

With proper dietetic regulation, the development of 
acidosis of a serious grade is unusual. The treatment 
of acidosis is mainly dietetic and preventive. Patients 
who show a tendency to acidosis while on a diet 
otherwise suitable should be frequently fasted. As has 
been mentioned^ however, a few jpatients develop 
acidosis of an alarming grade during the fasting 
period, as shown by the characteristic symptoms and 
by a progressive fall of the carbon dioxid tension of 
the alveolar air. The normal tension is in the neigh- 
borhood of 40 mm. ; a tension as low as 35 mm. may 



350 ALKALI THERAPY 

be considered as insignificant; tensions below 35 mm. 
indicate acidosis, and 20 mm. is to be considered the 
danger point. When such a degree of acidosis is 
approached during a fasting period, the indication is 
to break the fast by allowing a restricted diet, chiefly 
of green vegetables. In such cases, subsequent fasting 
frequently causes the acidosis to disappear. 

Alkali Therapy. — Dietetic treatment prevents the 
formation of acetone bodies and is the rational treat- 
ment for acidosis. Occasionally, however, the acidosis 
may become of such a grade that the administration of 
alkali is required. Alkalies neutralize acids already 
produced and replenish the depleted alkali reserve of 
the body, but have no effect in inhibiting the produc- 
tion of acids. Alkali administration is merely a 
temporary means of checking acidosis, but a valuable 
procedure when acidosis is of a severe enough grade 
to .threaten life. Alkali therapy should not in any 
measure replace dietetic regulation and should be used 
only to tide the patient over a critical period. Alkali 
is indicated when, as a result of the patient's failure to 
observe dietetic regulation, the alveolar carbon dioxid 
tension has fallen to 20 mm. or lower, or if coma is 
present, or obviously impending, and also when, as a 
result of fasting, progressive acidosis occurs which is 
not promptly checked by feeding green vegetables. 

Alkali in the form of sodium bicarbonate may be 
administered by mouth, by rectum, intravenously or 
subcutaneously. The amount necessary is determined 
by the degree of acidosis, the size of the patient, and 
the therapeutic result obtained as gaged by rise in 
carbon dioxid tension and symptomatic improvement. 

Sodium bicarbonate in solution may be given by 
mouth. In adults, it is usually futile to give less than 
4 gm. at a dose, which may be repeated every four or 
five hours. Doses larger than 15 gm. are generally not 
well tolerated. Alkali should be continued until the 
alveolar carbon dioxid tension has risen above 30 mm. 

By rectum, the drop method should be utilized, giv- 
ing equal parts of physiologic saline and 4 per cent, 
sodium bicarbonate solutions. 

Many diabetics, especially those approaching coma, 
are unable to retain alkali when given by mouth, on 




TREATMENT OF ACIDOSIS 351 

account of nausea and vomiting. In such cases and, 
in all serious cases in which alkali is required, intra- 
venous injection is the method of choice. A 4 per cent, 
solution of sodium bicarbonate may be used and as 
much as 500 c.c. injected slowly at a time. The injec- 
tion may be repeated as often as indicated by the 
alveolar air findings or by the symptoms. Since boil- 
ing changes bicarbonate into carbonate it is necessary 
to have the bicarbonate solutions specially prepared 
either by filtration through porcelain filters or using 
chemically pure bicarbonate in sterile water or physio- 
logic saline solution. 

TREATMENT OF ACIDOSIS 

Stillman (Arch, Inter. Med., 24, 445 (October), 
1919) suggests that active treatment be instituted for 
severe acidosis when the plasma bicarbonate C0 2 falls 
below 30 volume per cent. In addition to giving 3 gm. 
of sodium bicarbonate per hour dissolved in cold water, 
he administers fluids by the mouth to the patient's 
limit, but not to the extent of causing nausea. It has 
been attempted to give 5,000 c.c. in twenty-four hours. 
Clear, strong coffee has been given to stimulate the 
renal action. Finally active catharsis by calomel and 
salts together with high colon irrigations have been 
instituted and the effects clinically have seemed bene- 
ficial. Continuous fasting has been applied directly 
and if from six to twelve hours' fasting together with 
the treatment described did not cause an increase in 
the plasma bicarbonate, light feeding was begun. This 
consisted principally of protein. As has been pointed 
out, carbohydrate is not burned in such cases, thus 
leading to the severity of the diabetes, and fat leads to 
the formation of ketone bodies and consequently direct 
increase in acidosis. Therefore, from 600 to 800 calo- 
ries have been given in the form of eggs and lean meat. 

INDIVIDUALIZATION OF THE DIABETIC 

Diabetics differ, as do normal persons, in many ways, 
and each patient should be treated according to the 
findings in his case. Thus individual diabetics vary 
greatly, not only in their ability to metabolize food 



352 COMPLICATIONS OF DIABETES 

without the appearance of sugar but also as to the 
factors which may produce symptoms of acidosis. 
Likewise diabetes may be complicated by other consti- 
tutional diseases, such as tuberculosis and syphilis, and 
it is a delicate problem to determine how far one may 
go to influence one condition favorably without pro- 
ducing great harm as related to the other. 

From what has been written it is quite apparent that 
the treatment of diabetes requires special knowledge 
and constant and intelligent care. Drugs, with the 
exception of the alkalies, are worthless, "organo- 
therapy" in real diabetes is a failure, many of the 
so-called "diabetic foods" are fraudulent, a laissez faire 
policy is fatal. The disease is combated only by man- 
agement of the diet, which requires as nice discrimina- 
tion in its use both as to quantity and quality as does 
any drug. Cooperation on the part of the patient is 
another requisite. When proper care and satisfactory 
cooperation can be obtained, the results are usually 
satisfactory. 

COMPLICATIONS AND SEQUELAE 

It should be remembered that a generalized and per- 
sistent furunculosis may be an unpleasant accompani- 
ment of diabetes. Diabetic gangrene is another con- 
dition which may appear in the course of this disease 
and necessitate operation. Operations on diabetics are 
notoriously dangerous and usually undertaken only 
when deemed a life-saving measure. 

Addis (Jour. A. M. A., April 3, 1915, p. 1130) con- 
siders the necessary preparation of diabetics for opera- 
tion. One method of preparing diabetic patients for 
operation is to give them a sugar and starch-free diet. 
This is a useless procedure, according to Addis, 
because, although it may reduce the degree of hyper- 
glycemia and the amount of sugar in the urine, it will 
not lessen any of the risks of operation; it is danger- 
ous, since it increases the chances of the onset of dia- 
betic coma. When operation is not immediately neces- 
sary, and especially in those cases in which the decision 
as to whether or not an operation shall be performed 
rests largely on the question as to how much danger 
would be run by the patient after the operation because 



DIABETES INSIPIDUS 353 

of his diabetic condition, it would be a great advantage 
to have some objective data to supplement the facts 
relative to this point, which can be gained by clinical 
observation. The quantity of sugar in the urine is no 
aid in this respect, for the special danger to life is the 
failure, not of the sugar, but of the fatty acid metabo- 
lism. The coma in which diabetic patients die after 
operation is, often at least, accompanied by the excre- 
tion in the urine of large amounts of unoxidized fatty 
acids, and there is good reason for believing that the 
condition is due to poisoning by these acids. The ina- 
bility of the kidneys to excrete large amounts of fatty 
acids is a factor in the production of diabetic coma. 
The giving of alkali helps the kidneys in this work. 
Before operation, therefore, it is "important to deprive 
the patient of fats for several days and to give alkali 
until the urine becomes alkaline, and to maintain 
if possible this alkaline reaction after operation. 
Neither success in inducing a storage of glycogen in 
the body before operation, nor in keeping the urine 
alkaline is an absolute barrier against diabetic coma. 
They are only pallative measures. All those circum- 
stances which unite together to produce shock are fac- 
tors which act as exciting causes of the condition 
known as diabetic coma. It is possible to mitigate the 
action of these agencies by the application of the prin- 
ciples of "anoci association." 

DIABETES INSIPIDUS 

This condition is recognized by the excretion of 
large quantities of non-sugar-containing urine, not 
directly due to an excessive intake of fluids (polydip- 
sia). Connected etiologically with this condition the 
following have been mentioned : cerebral irritation, dis- 
eases and injuries of the cerebrum, diseases of the 
pituitary body and, finally, a primary cause in the 
kidney. 

The diagnosis of the cause of diabetes insipidus hav- 
ing been made, the treatment may be aimed more or 
less successfully to cure the condition, or to prevent the 
operation of the cause. A simple polyuria from over- 
drinking can, of course, be easily prevented. Nervous 



354 PELLAGRA 

causes may be modified if there is not actually some 
pathologic condition in the brain. If the blood-pressure 
is high, the lowering of it by proper baths, massage, 
physical exercise, change to a warm climate, diet, or by 
vasodilators will prevent it. Polyuria may, however, 
occur with low blood pressure, caused by some 
disturbance of the brain, as theoretically low blood 
pressure should not cause diabetes insipidus. Such 
instances may be helped by the vasoconstrictor drugs, 
and especially by ergot. It is possible that this effect 
of ergot is due to its action in preventing cerebral 
irritation, cerebral congestion, and possibly the slight 
cerebral exudate that may occur. There seems to be a 
definite relationship to pituitary gland disturbance in 
many cases and Lereboullet and others claim subcu- 
taneous injection of pituitary extract has symptomatic 
benefit. 

PELLAGRA 

The zeistic theory of the origin of pellagra is not yet 
entirely abandoned, and some students of the subject 
are still endeavoring to connect the incidence of pella- 
gra with some factor related to maize, or Indian 
corn, in the diet. Interest also centers in the broader 
hypothesis that pellagra is due to some communicable 
factor and should be placed in the category related 
to that of infectious disease or that it is essentially a 
deficiency disease. The Thompson-McFadden Pella- 
gra Commission has stated that its efforts to discover 
the essential pellagra-producing food or the essential 
pellagra-preventing food have not been crowned with 
success. Their evidence suggests that neither sub- 
stance exists in the population studied by them. Hence 
they have been inclined to postulate a communicable 
agency in the etiology of pellagra. In recent studies in 
South Carolina they found new cases of pellagra 
always occurring in communities where old ones 
existed, and also that improved sewage arrangements 
favorably influenced prevention of new cases. Gold- 
berger of the U. S. Public Health Service and his asso- 
ciates announced the experimental causation of pellagra 
in a group of human beings, as well as the cure and pre- 
vention of the disease among three groups of persons 
widely separated from each other geographically. As 



TREATMENT OF PELLAGRA 355 

a result of epidemiologic studies, Goldberger concluded 
that pellagra is not a communicable disease, that it 
is dependent on some as yet undetermined fault in a 
diet in which the animal or leguminous vegetable com- 
ponent is disproportionately large, and that no pellagra 
develops in those who consume a mixed well-balanced 
and varied diet. Positive experiments in feeding have 
led to the more definite belief that pellagra is a nutri- 
tional disturbance and should be treated on that basis. 
This is the view having greatest credence and support 
today and indeed, the establishment of proper feeding 
seems to have lowered greatly the incidence of pellagra 
in the southern part of the United States. 

TREATMENT OF PELLAGRA 

According to Voegtlin (Jour. A. M. A., Sept. 26, 
1914), all physicians who have had much experience 
in the treatment of pellagra agree on one point; 
namely, that in the milder cases the symptoms will 
almost always disappear in a relatively short time if 
the patients are kept in a hospital, at rest, on a lib- 
eral mixed diet, with plenty of fresh meat. He has 
found drugs of little value but calls attention to the 
use of arsenic, which has been highly recommended 
by Lombroso. He warns especially against placing 
the slightest faith in proprietary pellagra "cures." 

In the hygiene of the disease, of greatest impor- 
tance is the avoidance of direct sunlight except in 
spring and summer. There seems to be no doubt that 
the skin of the pellagrin is hypersensitive to sunlight. 

Diet. — Corn bread and corn products are prohibited 
until the zeistic theory is disproved, as a precau- 
tionary measure. The diarrhea does not indicate a 
limitation in the dietary regimen. Steak, roast beef or 
mutton may be allowed once or twice daily; if the 
mouth is too sore to allow chewing, beef or white 
meats, either scraped or ground, may be substituted. 
Eggs are generally permissible. Sweet milk is valu- 
able when it agrees with the patient. Fresh or arti- 
ficially soured buttermilk is nearly always suitable. 
The patient should be nourished to the limit of 
assimilation. Goldberger advises that beans and peas 



356 TREATMENT OF PELLAGRA 

may be eaten if fresh meat cannot be secured. In the 
winter the dried, not the canned, variety of the veg- 
etables should be as large a part of the diet as they 
form in summer. Vedder has formulated the follow- 
ing simple rules for the prevention of deficiency 
diseases : 

i. In any institution where bread is the staple article 
of diet, it should be made from whole wheat flour. 
2. When rice is used in any quantity, the brown under- 
milled, or so-called hygienic, rice should be furnished. 
J. Beans, peas or other legumes known to prevent 
beriberi, should be served at least once a week. Canned 
beans or peas should not be used. 4. Some fresh 
vegetable or fruit should be issued at least once a 
week and preferably twice a week. 5. Barley, a 
known preventive of beriberi, should be used in all 
soups. 6. If cornmeal is the staple of diet, it should 
be yellow meal or water-ground meal, that is, made 
from the whole grain. 7. White potatoes and fresh 
meat, known preventives of beriberi and scurvy, 
should be served at least once a week, and preferably 
once daily. 8. The too exclusive use of canned goods 
must be carefully avoided. 

As an illustration of the practical application of the 
above recommendations for a health-preserving, pel- 
lagra-preventing diet, Goldberger presents the follow- 
ing bill of fare : Breakfast — Sweet milk, daily; boiled 
oatmeal with butter or with milk every other day; 
boiled hominy grits or mush with a meat gravy or 
with milk every other day; light bread or biscuit (one- 
fourth soy-bean "meal) /with butter, daily. Dinner — 
A meat dish (beefstew, hash, or pot roast, ham or 
shoulder of pork, boiled or roast fowl, broiled or fried 
fish, or creamed salmon or codfish cakes, etc.), at least 
every other day; macaroni with cheese, once a week; 
dried beans (boiled cowpeas with or without a little 
meat, baked or boiled, soy beans with or without a 
little meat), two or three times a week; potatoes (Irish 
or sweet), four or five times a week; rice, two or 
three times a week, on days with the meat stew or the 
beans; green vegetables (cabbage, collards, turnip 
greens, spinach, snap beans or okra), three or four 
times a week; corn bread (one-fifth soy-bean meal), 



MEDICINAL TREATMENT OF PELLAGRA 357 

daily; buttermilk, daily. Supper — Light bread or bis- 
cuit (one-fourth soy-bean meal), daily; butter, daily; 
milk (sweet or buttermilk), daily; stewed fruit 
(apples, peaches, prunes, apricots), three or four times 
a week, on days when there is no green vegetable for 
dinner; peanut butter, once or twice a~week; syrup, 
once or twice a week. 

This bill of fare is primarily for older children and 
adults. The intelligent housewife will make such 
modifications as the age of her children, tastes and 
particular circumstances make necessary. The quan- 
tities of some of the foods may be reduced and 
replaced, in part or in whole, by other similar foods, 
but so far as possible no reduction should be made in 
the quantities of milk and lean meats. In the case of 
young children eggs make a very desirable addition 
and the relative quantity of milk allowed them may 
advantageously be increased. 

MEDICAL TREATMENT OF PELLAGRA 

As has been said, experiments with the feeding of 
pellagrins along the lines outlined by Goldberger have 
resulted in marked improvement, and as a result, much 
of the hypermedication formerly administered to 
patients with this disease has been discontinued. How- 
ever, the symptoms of the condition are frequently 
severe, and these should be alleviated by appropriate 
measures. The diarrhea, the constipation, the sore 
mouth, the nausea, or other concomitants of this dis- 
ease should be treated by the usual measures employed. 
The simple erythematous rashes or even sloughs of the 
skin of the hands and feet may be benefited by bland 
ointments such as zinc oxid or weak boric acid. Raw 
or weeping surfaces may be soothed by calamine and 
zinc oxid lotion in lime water. If there is intense burn- 
ing of the hands and feet, cold compresses of- a mild 
solution of phenol; 60 grains to the pint of water may 
be applied to the unbroken skin. Neuralgic pains may 
be treated by the usual dosages of acetanilid or acetyl- 
salicylic acid. 

Hydrotherapy has in many instances proved so ben- 
eficial in pellagra that some form of it, such as hot or 
cold baths, simple or medicated douching, packs, 



358 GOUT 

moist or dry rubs, accompanied by special massage, 
may be employed in nearly every case. Increased oxi- 
dation of the tissues, more rapid elimination, greater 
metabolic activity, sharpened appetite, improved diges- 
tion and assimilation, and a noticeable tonic effect on 
the whole living organism follow their use. 

GOUT 

ETIOLOGY 

The exact etiology of gout is as yet unknown. There 
are, however, numerous factors so constantly asso- 
ciated with this condition as almost to assume the 
nature of primary etiologic influences. The disease 
seems primarily to be a hereditary or acquired inability 
of the patient to properly metabolize purin bases. The 
disease occurs usually among the well-to-do ; those who 
are heavy eaters or indulge in alcohol, and it is com- 
monly associated with mental strain, fatigue or history 
of exposure. 

SYMPTOMATOLOGY 

The symptom ordinarily considered almost pathog- 
nomonic of gout is the occurrence of sudden pain in a 
metatarsal phalangeal joint, associated with all the signs 
of acute inflammation such as redness, swelling, tem- 
perature, moderate leukocytosis, etc. Accompanying 
the acute attack there is an excess of uric acid in the 
blood and urine, but the excretion of both endogenous 
and exogenous uric acid is diminished except during 
the acute seizure. In the chronic form of the disease 
the joints affected become thickened and deformed, 
tophi form, chalky deposits - develop, and the patients 
suffer with shooting pains, increased arterial tension 
and gastric disturbances. The tophi will be found to 
consjst of urates. 

TREATMENT 

In view of our inexact knowledge of the etiology of 
this disease, treatment is directed toward increasing 
the elimination of uric acid and lessening its formation. 

The food of the gouty patient must be regulated 
from every point of view; the intake of purins must 
be restricted; the intake of carbohydrates must be con- 
trolled to avoid glycosuria, from which gouty patients 



GOUT 359 

sometimes suffer; the habits of the patient must be 
regulated to secure proper eating and elimination of 
waste products. Chace has outlined a diet free from 
purins for use during the acute attack of gout : 

Breakfast: Apple or banana, cream of wheat or farina with 
cream and sugar, one egg, cup of cereal coffee with cream and 
sugar, toast and butter. 

Dinner: One egg, baked potato with butter, string beans, 
rice or macaroni, baked apple with sugar, a glass of milk. 

Supper: Rice with butter, cream cheese, bread and butter, 
stewed pears, rice pudding. 

By determining the eliminative capacity of the body 
for exogenous uric acid, it is possible to keep the intake 
of purins well within the limit. The continuous use of 
alkaline drinking waters causes a deposit of sodium 
urate in the joints and cartilages, and such drinks 
should be forbidden. Salt should be used very spar- 
ingly also, as it* tends to the formation of the sodium 
urates. Tea, coffee and cocoa are especially rich in 
purins. Fresh vegetables, except beans, peas and the 
various cereals, except oatmeal, may be freely eaten. 

General Measures. — Again it must be stated that 
patients differ and that the methods which are 
extremely successful with one may fail utterly with 
another. The patient must be individualized. Diet 
may produce marked improvement with no other mea- 
sures, but it is better to make the patient's whole life 
hygienically efficient. If his habits are sedentary he 
should be encouraged to outdoor life with suitable 
exercise. He should, however, be protected from 
undue exposure to the elements. All excesses should 
be subdued. Treatment at spring resorts is sometimes 
efficacious through the ability to enforce a hygienic 
regime when such efforts have failed at home. 

Medicinal Treatment. — In an acute attack proper 
care must be given to the affected joint. Those mea- 
sures which have been recommended under acute rheu- 
matic fever may be tried, especially wrapping the joint 
well in protective heating bandages and the local 
application of heat. The movements of the bowels and 
kidneys should be regulated and elimination through 
the skin encouraged by appropriate hot baths and 
packs. 




360 OBESITY 

The administration of the wine of colchicum, 8 to 
15 minims (0.5 to 1.0 c.c.) has been the classical 
treatment for the acute attack in gout. During suc- 
ceeding days half this dose is given. Colchicum may 
produce marked irritation of the intestines with watery 
stools and pain. This should be taken as evidence of 
sufficient action and the drug stopped. In non-nephritic 
cases salicylates may be given to encourage the elim- 
ination of uric acid. More recently phenylcinchoninic 
acid or cincophen, formerly called atophan, has been 
widely used. It seems to have a selective action on the 
excretion of uric acid. The drug should be adminis- 
tered every three hours, as its action diminishes rapidly. 
In the acute attack of gout it is sometimes beneficial 
in reducing pain. It should probably be the drug of 
first choice in the medicinal treatment of this disease. 
In acute gouty attacks it relieves more promptly than 
colchicum and without undesirable by-effects. 

OBESITY 

Obesity is a condition accompanied by the accumu- 
lation of extraordinary, therefore pathologic, quanti- 
ties of fat. Unless causing definite functional dis- 
turbance, no treatment is necessary. A reference to 
the table of height and weight at varying ages in the 
front section of the book will indicate what is normal. 

The treatment of obesity must include primarily a 
regulation of the diet to prevent the feeding of excess 
food over what the body can utilize and a regulation 
of body work to produce a demand for energy-giving 
constituents. 

DIET 

The number of diets which have been offered for 
obese persons is almost legion. Certain general prin- 
ciples must be observed, An average of several of 
the best known diets is as follows : Protein, 140 gms., 
fat, 40 gms., carbohydrates, 90 gms., calories, 1,320. 
It can be taken as a matter of fact that most people 
eat too much. The appetite may be better controlled 
and hunger appeased by small quantities of food 
taken frequently. Depressing of the appetite is com- 
monly advised and may be accomplished in several 



OBESITY 361 

ways, notably by long chewing of the food and limita- 
tion of the variety. Peppermint lozenges and menthol 
tablets reduce the sensibility of the mucosa of the 
stomach and minute doses of camphor seem to produce 
a feeling of fullness. Coffee taken early in the meal 
has long been advocated by Steinberg as it reduces 
appetite and lessens the usual desire of the overcorpu- 
lent to sleep. 

Friedenwald and Ruhrah give the following general 
directions: Avoid sugars and starchy food and take 
little or no fatty food. Eat sparingly and take but 
little fluid — and that apart from meals. Obese persons 
may eat small quantities of chicken, beef, oyster, bouil- 
lon or clam soups ; meat once daily consisting of beef, 
lean, raw, scraped, boiled or broiled; steak, broiled; 
mutton, roasted; chops, broiled; chicken, boiled or 
broiled. Eggs should be only soft boiled or poached. 
Of fish the following may be taken: oysters, raw; 
mackerel or trout. Of bread, but a small quantity 
should be allowed and then only in the form of stale 
wheat bread, zwieback, toast, graham or gluten bread. 
The following fruits, all of which are acid, may be 
recommended : lemons, oranges, raw apples, grapes, 
raw peaches, berries and cherries. Water should be 
taken sparingly at meal times. Tea and coffee may be 
taken but without sugar or milk. Mineral waters ordi- 
narily may be allowed in quantity sufficient to assuage 
thirst without causing disagreeable symptoms. 

The following articles of diet should not be taken: 
rich soups, fried foods, pork, veal, stews, hashes, potted 
meat, liver, duck, goose, sausage, crabs, lobsters, pre- 
served fish, salmon, bluefish, herring, hominy, oatmeal, 
rice, puddings, sardines, potatoes, turnips, carrots, par- 
snips, sweet potatoes, beets, hot bread or cakes, nuts, 
candies, pies, pastry. 

HYDROTHERAPY 

The use of cold baths in the treatment of obesity, as 
well as special forms of hydrotherapy, is generally 
well known. Besides improving the skin and aiding 
the circulation, it seems likely that such baths also 
accelerate the loss of fat. 



362 MEDICINAL TREATMENT OF OBESITY 

EXERCISE 

In the presence of circulatory disorders, the pre- 
scribing of exercise must be cautious ; otherwise it is a 
valuable aid in producing loss of weight. 

Walking and horseback riding, swimming and 
graded calisthenics, may be of value. Golf and tennis 
may be likewise indicated if the physician thinks 
proper. 

Massage (if given vigorously and accompanied by 
passive motion) sometimes produces marked results, 
especially in those of established sedentary habits. 

The Zander aparatus produces passive mechanical 
exercise. Besides such machines others combining 
weight lifting, pushing, pulling and stretching move- 
ments may be employed in suitable cases. 

MEDICINAL TREATMENT 

Obesity cures of a fraudulent nature are legion. 
In most instances they are either dangerous or worth- 
less, or both. Thyroid extract has been and still is the 
basis of many so-called "fat reducers." Lemon juice 
has had its day and numerous iodid preparations have 
been exploited. Bladderwrack, a form of seaweed, 
has likewise had a peculiar vogue. 

Von Noorden believes there is an endogenous con- 
stitutional type of obesity which he regards as trace- 
able to thyroid functioning. Congenital or acquired 
weakness or degeneration of the thyroid may induce 
the obesity directly or the thyroid may become a factor 
in the obesity only secondarily; disease in the ovary 
or testicle (deficiency of the interstitial substance) ; 
disease in the pituitary body (adipose-genital dys- 
trophy) ; disease in the pineal gland or thymus (both 
dubious). There may also be a combination of both 
the exogenous and endogenous type, especially in the 
young. 

Throughout the endogenous forms, abnormal thyroid 
functioning is common to all, and treatment of consti- 
tutional obesity must be based on thyroid treatment. 
It is unquestionable now that the reliance on thyroid 
treatment is increasing, the dread of it diminishing. 



TREATMENT OF OBESITY 363 

The dangers from thyroid treatment are just as 
great as ever, but we know better how to watch 
out for them and guard against them. He adds 
that even in cases amenable to systematic dietetic 
measures alone, the prolonged restriction of the diet 
seems to him more of an evil than a course of thyroid 
treatment. With this the diet need not be' so strictly 
regulated and the effect of the thyroid treatment is 
often permanent, so that the patients can eat like 
other people afterward without bringing back the 
obesity. During the thyroid course ample provision 
of albumin should be ensured. The urine should be 
examined often for sugar. The tendency to acceler- 
ation of the heart action and to lowering of blood pres- 
sure can be warded off by daily small doses of some 
digitalis preparation. The thyroid seems to lead to an 
increase of oxygen consumption and carbon dioxid 
excretion. If used it may be given in doses of one to 
two grains twice or three times daily and increased 
only very cautiously. 

ROUTINE OF TREATMENT 

The patient who wishes to be scientifically treated 
for obesity must be willing to place himself unreserv- 
edly in the hands of his physician for a long period of 
time, six months to a year, and to obey all instructions 
implicitly. The treatment is begun by a study of the 
patient's habits as to life and diet. Mild exercise and 
restrictions of the diet gradually become increasingly 
severe and strenuous, and during the second or third 
month, massage, use of mechanical apparatus and 
organotherapy may be attempted. The patient should 
be weighed regularly with and without the clothing. 
The patient will have much to overcome in the way of 
advice and ridicule from friends, and the physician 
must, as suggested by Romero, be on the lookout for 
complicating factors in his case raised in this way. As 
has repeatedly been shown both by medical and non- 
medical experiments in the reduction of weight of 
groups of the obese, systematic controlled treatment 
by appropriate measures is almost invariably successful. 



DISTURBANCES OF THE HEART 



Of late years the disturbances of the heart are begin- 
ning to assume a more prominent place in the list of 
causes of death. Only tuberculosis and kidney dis- 
turbances are more prominent. Although the majority 
of sudden deaths are due to a cardiac cause, there are 
few chronic diseases so amenable to treatment and so 
compatible with long life and comfort, if judiciously 
handled, as cardiac cases. Of late years also there have 
come into prominence numerous delicate methods of 
examining the heart's functioning, testing its rate and 
its rhythm. These newer methods have pointed the 
way toward efficacious therapeutic measures. 

THE PREVENTION OF CARDIAC DISTURBANCES 

Although we shall consider under each heading the 
various elements in the etiology, it may be worth while 
here to take up some of the more general factors 
which produce cardiac disturbances. 

Recent studies of focal infections have shown that 
a tonsillitis, an abcessed tooth, or other focus of infec- 
tion may be the origin of germs that later may cause 
an endocarditis, or valvular infection. Patients are 
likely to manifest a desire to become active too soon 
after a serious illness or a surgical operation. The 
physician or surgeon should not submit his patient 
to such strenuous cardiac tests. If the patient mani- 
fests a marked rapidity in the heart rate on first sitting 
up in bed, cautious consideration should be given to 
his symptomatology before allowing him to arise. All 
physicians are probably familiar with the serious car- 
diac disturbances in young men who have indulged too 
vigorously in modern athletic competition. 

HYPERTENSION 

THE BLOOD PRESSURE 

It is presumed that the physician is familiar with the 
methods of determining the systolic and diastolic 
blood pressures and with the significance, of variations 



ETIOLOGY OF HYPERTENSION 365 

in the readings from the normal. The average pres- 
sure pulse is about 35 to 40 mm. (difference between 
systolic and diastolic pressures). Faught states his 
belief that the relation of the pressure pulse to the 
diastolic pressure and the systolic pressure is 1, 2, 3. 
In other words, a normal young adult with a systolic 
pressure of 120 should have a diastolic pressure of 80, 
and therefore pulse pressure of 40. If these relation- 
ships become markedly abnormal disease is developing 
and imperfect circulation is in evidence, with the dan- 
ger of broken compensation occurring some time in 
the future. It should be remembered that the diastolic 
pressure represents the pressure which the left ven- 
tricle must overcome before the blood will begin to 
circulate, that is, before the aortic valve opens, while 
the pulse pressure represents the power of the left 
ventricle in excess of the diastolic pressure. A high 
diastolic pressure is of serious import to the heart; a 
diastolic pressure over 100 is significant of trouble 
and over 110 is a menace. A pressure higher than 150 
is serious, and anything over 200 usually indicates 
renal insufficiency. 

ETIOLOGY OF HYPERTENSION 

One of the most common causes of hypertension is 
excess in eating and drinking. The toxins from excess 
food are irritating, and therefore one of the first steps 
toward improving and lowering blood pressure in 
such cases is to diminish the amount of meat eaten or 
to remove it entirely from the diet. Alcohol, by affect- 
ing the appetite and increasing the amount of food 
taken, by interfering with the activity of the digestive 
tract, can indirectly disturb metabolism and thus affect 
the blood pressure. It should always be eliminated. 
Drugs or other substances that raise the blood pressure 
by stimulating the vasomotor center or the arterioles, 
when constantly repeated, may cause hypertension. 
This seems to be particularly true of caffein and nico- 
tin as taken in the form of coffee and tobacco. Thayer 
found a distinct relationship of hypertension to hard 
work. With such work is usually associated a hyper- 
secretion of the suprarenals. Neurotic conditions, and 
in some instances neurasthenic conditions, may show 



366 PREVENTION OF HYPERTENSION 

a blood pressure higher than normal. Lead may be 
a cause of increased blood pressure, and diabetics 
occasionally have a high pressure, although more fre- 
quently there is a lowering of blood pressure in dia- 
betes. Syphilis, as shown by Riesman, Levinson and 
others, is a very common cause of hypertension and 
arteriosclerosis without renal disease. When arterio- 
sclerosis and renal disease are combined, the highest 
systolic readings occur. Riesman, Hopkins, Gutmann, 
and more recently Engelbach {Jour. A.M. A., 74, 1619, 
June 12, 1920) have reported instances of hyperten- 
sion referable to the menopause and alterations in the 
internal secretions. Engelbach found most of his cases 
associated with polyglandular insufficiency. In such 
cases treatment is pointed toward correcting the dis- 
turbed internal secretory balance. 

PREVENTION OF HYPERTENSION 

The physician should continually caution the patients 
in whom the factors leading toward hypertension 
exist against the many things which will propagate 
and prolong that condition. They should be cautioned 
against severe athletic competition, recreation excesses, 
excessive use of tobacco, alcohol, and caffein, and over- 
eating. The pregnant woman should be carefully 
watched for changes in the urine and in the blood 
pressure. Patients with infectious diseases should 
have a slow convalescence during which they are care- 
fully watched in order to prevent throwing too great 
a strain on weakened organs. 

Stoll has outlined a short series of "Don'ts" for 
patients with hypertensive cardiovascular disease, 
which are of distinct service in keeping the etiology 
and prevention of these conditions in mind : 

i. Don't tell the patient with moderate hypertension, 
few symtoms and whose kidneys are functioning 
well to stop eating meat or to go on a milk diet. 

2. Don't tell him to immediately give up his business ; 
try to readjust his life so that unnecessary cardiovas- 
cular strain is reduced to a minimum. 

J. Don't tell him his kidneys are "all right," just 
because his urine exhibits neither albumin nor casts. 



PREVENTION OF HYPERTENSION 367 

4. Don't miss the significance of nocturnal polyuria 
and a persistently low gravity. 

5. Don't give nitroglycerin tablets to your patient 
the moment you discover that he has hypertension. 
Perhaps he requires a high pressure to get the blood 
through his small inelastic vessels. 

6. Don't be satisfied with the systolic pressure — the 
diastolic is often of more significance. 

7. Don't attribute the insomnia, nervousness and 
headaches in the middleaged woman to "the change" 
— take her blood pressure and examine her eye 
grounds. 

8. Don't make a diagnosis of neurasthenia till after 
a blood pressure estimation and a Wassermann test. 
It may save subsequent embarrassment and even be 
of advantage to the patient. 

9. Don't think you are doing your whole duty to 
your pregnant patient when you have examined her 
urine. She may have hypertension but no albumin 
today and eclampsia next week. 

10. Don't consider hypertension solely a condition of 
middle life; it is occasionally present in childhood. 

11. Don't forget the old man's enlarged prostate. 
It may be the cause of the nephritic syndrome. 

12. Don't hesitate to give digitalis when symptoms 
of cardiac failure are evident. It will not raise the 
blood pressure. 

13. Don't wait until the patient is water logged and 
the heart dilated before suspecting a failing myocar- 
dium. 

14. Don't deny your sleepless, gasping patient, whose 
course is nearly run, the relief that only morphin will 
give. 

15. Don't make a prognosis solely on the blood 
pressure or the phenolsulphonephthalein test. Each 
tells but part of the story. 

16. Don't overlook the fact that cardiovascular dis- 
ease is to a certain degree a familiar condition some- 
times present in several generations; nor neglect to 
explain the importance of a yearly blood pressure 
estimation of all members of the familv. 

17. Don't exclude syphilis, especially a parental 
infection, as the cause of the hypertension solely 



368 TREATMENT OF HYPERTENSION 

because the Wassermann is a negative. ' Study the 
family history; examine the brothers and sisters, and 
your patient's children for signs of hereditary syphilis. 
18. Don't fancy that the management of hyperten- 
sion consists in watching a column of mercury or that 
.success is measured in millimeters. 

TREATMENT OF HYPERTENSION 

Active treatment in hypertension should begin with 
a thorough cleansing of the gastrointestinal tract by 
purgation. Following this the most important mea- 
sure in the management of high blood pressure is the 
proper regulation of the personal habits and diet. Con- 
stipation should be kept under control by feeding fruits 
and vegetables, avoiding those that produce flatulency. 
The embargo on meat foods should be absolute at first 
and these things added to the diet according to the 
response of the patient to them. Alcohol, tea and 
coffee should be forbidden. The patient should be 
encouraged to drink milk if it agrees with him. If the 
patient can be sure of good excretion, large quantities 
of fluid may be taken ; but it is very important that the 
elimination be watched; if an appreciable portion of 
the fluid remains it adds quantity to the fluid in the 
blood vessels and thus does harm. Allen {Jour, A. M. 
A., 74, 652 (March 6), 1920) has especially empha- 
sized the value of salt restriction and water restriction 
in cases of so-called pure hypertension as well as in 
nephritis. 

A patient with simple hypertension but otherwise 
well should have recreation periods one or more times 
a week and vacations not too infrequently. He should 
take a brisk purgative perhaps once in a fortnight or 
once in a week. Such physical methods as sweat 
baths, electric light baths and similar measures may be 
utilized as occasion demands. If there is insomnia a 
dose of chloral may be given as needed but this 
should not be continued over long periods. If any 
other drug is needed nitroglycerin may be tried. If 
arteriosclerosis is present sodium iodid in small doses, 
3 grains (0.2 gm.) two or three times a day may be 
serviceable. 



DRUGS IN HYPERTENSION 369 

Probably the one measure of greatest importance in 
these cases is sufficient rest in bed. Freedom from 
either physical or mental strain is an important factor 
in lowering the blood pressure. Hydrotherapeutic 
measures, including the use of properly controlled heat 
and sweat baths, must be considered with relation to 
each patient's condition. 

After a period which may be termed the normal 
period of hypertension in normal life, as age advances 
the systolic tension may lower, provided there is no 
kidney lesion. This is due to the slowly developing 
chronic myocarditis and a lessening of the tension 
and therefore lessening of the resistance to the heart. 

When the blood pressure is suddenly excessively 
high from any cause venesection may be life saving 
and should perhaps be more frequently utilized than 
it is. It may save a sudden heart attack or a cerebral 
hemorrhage. Patients with high tension may be bled 
frequently and as much as half a pint taken at a time. 
Such treatment, however, will not long save life, as the 
blood pressure in most cases soon returns to its previ- 
ous height. 

DRUGS IN HYPERTENSION 

The drugs that are most commonly used to lower 
blood pressure are the nitrites or drugs of that class 
including nitroglycerin, sodium nitrite, erythroltetra- 
nitrate and amyl nitrite. Other drugs more rarely 
used are iodids, thyroid, alkalies, chloral, bromids and 
very rarely aconite. 

Amyl nitrite is required only when a sudden imme- 
diate effect is desired in angina pectoris or in some 
other serious spasmodic condition. Sodium nitrite 
is more likely to upset the stomach than is nitro- 
glycerin. Its action is more permanent, however. 
The dosage is from 0.03 gm. to 0.06 gm. (y 2 to 1 
grain) best given in tablet form with plenty of water. 
The tablets may be crushed before swallowing. Nitro- 
glycerin, in doses of from 1/500 to 1/100 grain, 
three or four times a day, in the form of a soluble 
tablet is a very popular drug. It acts iti two or three 
minutes and the blood pressure may drop twenty or 



370 ACUTE PERICARDITIS 

more millimeters. Thyroid extract seems to act bene- 
ficially in many cases and if no tachycardia is present 
it may be tried. 

Actually drugs, except at times organotherapy, 
promise very little in the control of this condition. 
Probably just as much can be accomplished through 
rest in bed, correct diet, free purgation, regulated exer- 
cise, venesection and appropriate hydrotherapeutic 
measures. 

ACUTE PERICARDITIS 

Pericarditis is almost invariably a secondary con- 
dition, the most frequent infectious cause being 
rheumatism, others being cerebrospinal meningitis, 
acute miliary tuberculosis, pneumonia and sepsis. 
Accidental causes are traumatism, and an adjacent 
inflammation of the pleura. Pericarditis may also be 
terminal in nephritis, adjacent abscesses, cancer and 
other new growths. The most important sign for 
diagnosis is the so-called friction rub, usually best 
heard in the fourth and fifth interspaces near the ster- 
num. It is caused partly by the exudate and partly 
by the state of the membrane. 

TREATMENT 

Of primary importance in the treatment of peri- 
carditis is rest. The patient should have absolute 
rest. He should not be allowed to sit up in bed, even 
to eat or attend to the calls of nature. He should 
have no visitors. Anything that increases the heart 
beat increases the irritation of the inflamed surfaces 
of the pericardium. 

Just what can be done logically or generally to com- 
bat the inflammation actively must depend on the 
cause. When the inflammation occurs as a complica- 
tion of acute rheumatism, it has been suggested that 
salicylates, which do not inhibit rheumatism and may 
be depressant to the heart, should be stopped if they 
are being administered ; but if the salicylates are 
apparently improving the inflammation in the joints, 
pericarditis would not contraindicate their continued 
use. Except in large doses, salicylates probably do 
not depress tne heart. In pericarditis it is generally 
well to administer an alkali in some form whether the 



TREATMENT OF PERICARDITIS 371 

cause is rheumatism or not. A diminished alkalinity 
of the blood would always increase the likelihood of an 
augmented amount of pericardial or endocardial inflam- 
mation. Alkalis may be freely given. It is possible 
that one of the reasons why pericarditis or endocarditis 
occurs so frequently in serious prolonged fevers is that 
the patient has not eaten enough cereals or other carbo- 
hydrates, and the system has become more or less 
endangered by acidosis. In other words, carbohydrate 
starvation is inexcusable with our present understand- 
ing of the danger from even a diminished amount of 
alkalis in the blood. 

The most valuable local treatment is cold, which 
may be applied either in the form of an ice-bag or by 
a small coil through which ice-water is caused to flow 
by siphonage. Cold may be applied more or less con- 
tinuously, depending on the sensations of the patient. 
The bag or ice-cap must not be overfilled and must 
not be heavy, as the patient often cannot stand pressure 
over the pericardium. Sometimes the relief from 
pain and the diminution of the number of the heart- 
beats is marked, and from this reason alone the cardiac 
inflammation may be inhibited. If cold applications 
are not tolerated by the patient (and they often are 
not in children) warm applications may be used, such 
as cloths wrung out of hot water and covered with 
oil-silk, and the pain will often be relieved thus. While 
hot application's would not tend to abort the inflamma- 
tion, they probably do not tend to promote it. 

The intake of food and especially of fluids should 
be decreased but the nutrition of the patient should 
not be allowed to suffer. 

A diminished diet, of small amount at a time, and 
such purging as the patient's strength will allow are 
essential in attempting to curtail the seriousness or 
amount of this inflammation. A too great quantity of 
fluids tends to increase tension and delay absorption. 

Stopping the Pain. — Nowhere else in the body 
should pain be so speedily combated as when it occurs 
in the region of the heart. Morphin should be admin- 
istered as needed to control the pain. The ice-bag may 
obviate the frequent need of morphin. If morphin is 



372 TREATMENT OF PERICARDITIS 

contraindicated other sedatives may be employed. 
Depressing measures should not be resorted to unless 
the state of the circulation is good. 

The Exudate. — It is not known how much is to be 
gained by indirect measures tending to prevent exuda- 
tion and hasten resorption of the exudates. However, 
purging, diuresis and local application of blisters have 
been employed for these purposes. The saline purges 
should be used only if the heart is strong. If the circu- 
lation is weak, the vegetable purgatives or calomel may 
be employed. 

For diuresis potassium citrate and, if deemed advis- 
able, digitalis, may be employed. However, if there is 
associated myocarditis, digitalis is contraindicated. 

If, in spite of all the therapeutic measures sug- 
gested, the fluid increases and the pericardium becomes 
more distended and the heart's action more labored, 
paracentesis must be done. The point where the 
aspirating needle should be inserted into the peri- 
cardium depends somewhat on the conditions in the 
individual case. It is often best to insert an explora- 
tory needle first. In cases where the apex cannot be 
localized, the sixth interspace near the mammillary line 
is frequently the point utilized. Thayer suggests that 
the physician seek a point a little outside of the sup- 
posed position of the apex if it can be definitely deter- 
mined that the heart is enlarged or dilated. Prelim- 
inary puncture will determine the fluidity and char- 
acter of the exudate. If pus is found, a more 
radical surgical procedure than simple paracentesis 
must be done immediately. The point of puncture for 
aspiration most frequently chosen is the fourth or 
fifth intercostal space, about an inch to the left of the 
sternal margin. Paracentesis is also often done in 
the region of the normal apex beat. The position of 
the patient is determined by his dyspnea; he should 
lie in the position most comfortable for him. The 
fluid should be withdrawn slowly and the pulse care- 
fully watched. The withdrawal of a small amount 
of fluid may later seem to be the starting cause of 
resorption of the rest of the fluid. On the other hand, 
it often accomplishes nothing but the removal of the 
immediate pressure, the fluid may again accumulate, 



MYOCARDIAL DISTURBANCES 373 

and more radical surgery must be performed. The 
amount of fluid withdrawn should not exceed 6 ounces 
at any one time.' 

Convalescence. — The convalescence should be pro- 
longed as in any other cardiac inflammation. The 
patient should be given more and more nourishing 
food, and a capsule containing 0.05 gm. of quinin and 
0.05 gm. of reduced iron, three times a day. 

It is a question as to when patients convalescent 
from pericarditis should be permitted exercise. It has 
been thought that gentle movements and possibly exer- 
cise, sooner than theoretically justified, might cause 
the heart to beat a little more actively and possibly 
prevent the formation of tight adhesions between the 
two layers of the pericardium. Whether such activity 
of the heart will prevent adhesions is something that 
has not been determined. 

Small doses of sodium iodid, perhaps 0.2 gm. (3 
grains), two or three times a day, should be continued 
for some time. Iodid in this dosage does no harm 
and may do a great deal of good in these cases. 

MYOCARDIAL DISTURBANCES 

The condition of the myocardium or heart muscle 
is often the determining factor as to whether a patient 
shall live or die. If the myocardium be degenerated 
at the end of a long severe illness, a too rapid attempt 
at a return to ordinary activities may bring about a 
dilatation of the heart which is itself responsible for 
sudden death or prolonged disability. 

HEART FUNCTION 

As Sir James Mackenzie has repeatedly emphasized 
most important in the examination of the heart is the 
study of how it responds to effort. For this purpose 
numerous functional tests have been proposed, varying 
from simple effort to those requiring elaborate appar- 
atus. Rapidity of the pulse and respiration two min- 
utes after hopping a hundred times on one foot was 
the test utilized in Army examinations. A rise of blood 
pressure after exercise normally occurs within thirty 
seconds. If this is delayed to more than a minute the 



374 ACUTE MYOCARDITIS 

heart's capacity has been exceeded. These function 
tests are of the greatest importance in outlining the 
patient's future work and habits. 

Acute Myocarditis 

Practically all acute infections cause more or less 
myocarditis. It is exceedingly rare, indeed, that an 
endocarditis occurs without an accompanying myo- 
carditis. The condition is not diagnosed until a sudden 
acute dilatation calls for emergency treatment. 

The symptoms are often indefinite. If an acute myo- 
carditis develops the apex beat is less positive, less 
accentuated and later diffuse and feeble. The closure 
of the aortic valve is less typically sharp, showing that 
the blood vessels are not so thoroughly filled. The 
peripheral circulation may- not be active, the blood 
pressure falls, and the heart becomes more rapid, 
especially after exertion. 

The prevention of this condition must be rest. 
Patients should not be allowed to attempt too rapid a 
convalescence after an infectious disease, a labor, or 
a surgical operation. Such cardiac tonics as digitalis 
should not be given ; fluids should be diminished. Vaso- 
contractors such as ergot should not be given; large 
amounts of food should not be taken into the stomach 
at one time. Massage may be of service to promote 
return circulation to the heart. No cardiac debilitating 
drug should be administered when myocarditis has 
been diagnosed. The safest hypnotic is morphin in 
small doses. Calcium may be of value in this condition, 
and perhaps the best salt to administer is calcium 
glycerophosphate in doses of 0.25 gm. (4 grains) three 
or four times in 24 hours. 

Chronic Myocarditis 

This is the term applied to a condition which is not 
an inflammation but a long continued degeneration. It 
is often a part of an arteriosclerosis. This being the 
case, the causes are all of the conditions which are 
associated with the appearance of arteriosclerosis : old 
age; syphilis; gout; repeated attacks of rheumatism; 
excesses, especially in food and alcohol; prolonged 
wasting diseases, such as tuberculosis or cancer. The 



CHRONIC MYOCARDITIS 375 

myocardial changes are sometimes associated 'with 
chronic pericarditis and chronic endocarditis, and may 
accompany or follow valvular diseases of the heart. 

The symptoms of chronic myocardial degeneration 
are progressive weakness, slight at first, noticeable on 
exertion; the pulse frequently becomes more rapid. 
There is likely to be edema of the lower extremities 
toward night. The amount of urine may diminish. 
The pulse may become intermittent, then irregular. 

The physical signs often show an enlargement of 
the heart. Such a heart may act perfectly until a 
sudden exertion causes it to weaken, giving cardiac 
distress signals, the patient becoming prostrated for 
a variable period. Slight cardiac pains and sensations 
referred to the cardiac region become frequent. 

TREATMENT OF CHRONIC MYOCARDITIS 

Patients with this disturbance should avoid physical 
effort and mental weariness ; should avoid the swamp- 
ing of the circulation with fluids; should reduce the 
quantities of food taken ; should cause daily free 
movements of the bowels; should take warm baths 
daily to clean the skin and promote perspiration; 
should take a correct amount of cautious exercise or 
undergo carefully directed calisthenics or massage. 
The patient should avoid chilling the body or placing 
any other sudden strain on the weakened heart mus- 
culature. Complete rest one day a week and one 
month in the year will aid in prolonging life. 

A diet of low protein content, from 60 to 70 gm. 
daily, especially if nephritis be associated, is better than 
the usual 120 gm. The intake of meat, strong soups 
and protein vegetables should be minimized and all 
articles causing intestinal fermentation eliminated. 
The dietary should, of course, be otherwise regulated 
to meet the individual case. 

If there is a high blood pressure nitroglycerin or 
other nitrites may be given. 

When an iodid is deemed advisable, the sodium salt 
is best, given either in a saturated solution or in a 
solution in water of which a dose would be a teaspoon- 
ful, well administered in milk. 



376 ENDOCARDITIS 

There is no syrup or tasteful menstruum that will 
well disguise the taste of an iodid. It is much better 
to give these preparations in water and allow the 
patient to take them either in milk or effervescing 
water, or in any solution that he may prepare to suit 
his taste, or he may follow the drug with any taster 
that he desires. 

Gm. or Cc. 

Ifc Sodii iodidi 201 or 3 v 

Aquae... q. s. ad saturandum | 

M. Sig. : Five drops, in water, three times a day, after 
meals. 

[Each minim represents about .065 gram (1 grain) of the 
drug. _ A drop, however, of a saturated solution is less than 
a minim.] 

If, in spite of this management and treatment, the 
patient has cardiac asthma attacks, with or without 
pain, especially if there are pendent edemas, the ques- 
tion arises as to whether or not digitalis should be 
given. In such cases one cannot tell without trying 
whether digitalis will be of benefit or will cause more 
discomfort. A small dose of an active preparation 
should be given at first twice in twenty-four hours, 
and after a week once in twenty- four hours, its action 
being carefully watched and the decision as to whether 
the dose is too large or too small arrived at. 

ENDOCARDITIS 

Acute endocarditis rarely, if ever, occurs without 
some myocarditis, and not infrequently pericarditis 
also accompanies these conditions. Endocarditis is 
divided for discussion into acute mild (simple) endo- 
carditis; acute malignant (ulcerative) endocarditis; 
chronic endocarditis and valvular disease. 

Acute Mild Endocarditis 

It has been shown positively that acute endocarditis 
is due to micro-organisms, generally streptococci, 
staphylococci, or pneumococci, and (more frequently 
than once believed) gonococci. The most frequent 
causes are acute rheumatic fever, diphtheria, pneu- 
monia, cerebrospinal meningitis, scarlet fever, ery- 
sipelaSjJnfluenza, chorea, gonorrhea, sepsis and typhoid 
fever. It may also follow a follicular tonsillitis which 



TREATMENT OF ENDOCARDITIS 377 

is rheumatic in type but has not caused arthritis. 
Tuberculosis may also occasionally cause an endo- 
carditis. 

This inflammation of the endocardium is generally 
confined to the region of the valves, and the valves 
most frequently so inflamed are the mitral and aortic. 
There may be a slight inflammation or actual ulcera- 
tion and loss of tissue. Vegetations more or less 
constantly occur on the inflamed surfaces, with more 
or less danger of particles becoming loosened and 
moving free in the blood stream, causing embolic 
obstruction of different parts of the body. There is 
also more or less probability of serious adhesions or 
contractions occurring from the healing of the ulcer- 
ated surfaces. In other words, the future health and 
welfare of the valves depends on the fact that the 
inflammation has healed without contractions or 
adhesions. 

It is often difficult to decide when acute endo- 
carditis has developed, but with the knowledge that 
the endocardium often becomes inflamed during almost 
any of the acute infections, the physician should 
repeatedly examine the heart for murmurs, for muffled 
closure of the valves, or for other evidences of endo- 
carditis or myocarditis during the acute infective 
process. 

SYMPTOMS 

Among the early symptoms of endocarditis, which 
is often not recognized until the appearance of a 
valvular lesion, may be pain or discomfort about the 
heart and a rise in temperature. Frequently also there 
may be some dyspnea. Patients so afflicted are usually 
nervous and restless, and inclined to show anxiety on 
even moderate exertion. 

TREATMENT 

In the treatment of mild acute endocarditis rest, both 
mental and physicial, is of primary importance. This 
should extend over four to six weeks and should 
be absolute. To counteract muscular flabbiness, mas- 
sage should be given, from simple rubbing and knead- 
ing to passive movements. 



378 MALIGNANT ENDOCARDITIS 

The medicinal treatment includes the use of alkalis. 
These may be given as potassium citrate in doses of 
2 gm., every three to six hours, in wintergreen water, 
If the salicylates are being given, as they should be, 
to counteract rheumatic infection, sodium bicarbonate 
may be given in equal dosage. To counteract the 
anemia likely to develop, iron may be administered 
as 5 drops of the tincture of the chlorid in lemonade 
or orangeade, twice in twenty-four hours. A 3-grain 
tablet of saccharated oxid of iron may be given twice 
in twenty-four hours. Pain may be combated by the 
use of morphin in adults or codein if the patient be a 
child. 

For marked nervousness and restlessness, the 
bromids may be of value; and in case of insomnia, 
chloral or sodium-ethyl-barbiturate may be used, a 
dosage of 3 to 5 grains being ordinarily sufficient. 

Diet. — The diet should at first consist largely of 
milk and cereals with a moderate amount of fluid and 
alkaline drinks. During convalescence a full diet may 
be prescribed, especially milk, eggs and fresh vege- 
tables. The bowels should be kept open but brisk 
catharsis is inadvisable. It is better to regulate the 
bowels by simple measures, such as proper foods, etc. 

The correct use of cardiac drugs is a difficult prob- 
lem. If there is myocardiac inflammation digitalis 
is inadvisable, as is the case in the presence of much 
endocardial inflammation. If there are signs of failure 
of the cardiac muscle, camphor or strophanthin have 
been advised when prompt stimulation is needed. 

For hyperpyrexia and profuse perspiration, the 
surface of the body should be sponged with lukewarm 
or warm water. Too profuse sweating may be com- 
bated with atropin. 

Malignant (Ulcerative) Endocarditis 
Ulcerative endocarditis may develop from the mild 
type or independently of it. It is essentially a septic 
process and develops from a local focus of infec- 
tion elsewhere in the body. The process may include 
disintegration of the heart muscle and deep points 
of erosion as well as little pockets of pus or abscesses 
in the muscle tissue. 



MALIGNANT ENDOCARDITIS 379 

The diagnosis is not so difficult if this condition 
develops on a mild endocarditis as when it appears 
primarily. The temperature is generally intermittent, 
accompanied by chills. There may be prostration and 
profuse sweats. 

Meningeal symptoms — headaches, restlessness, deli- 
rium, stupor — are not uncommon and convulsions may 
occur. Enlargement of the spleen and congestion of 
the liver may be found. Albumin appears in the 
urine. Definite cardiac symptoms and cardiac weak- 
ness eventually dominate the picture. Ecchymotic 
spots may appear over the body. If emboli break off 
and are carried to different parts of the body they 
bring about symptoms of embolism in that part. If 
mycotic, they may set up a local focus of infection; 
if lodging in a terminal artery, gangrene of the part 
concerned takes place, necessitating amputation, or 
perhaps being itself the cause of death. 

TREATMENT OF MALIGNANT ENDOCARDITIS 

The treatment of malignant endocarditis includes 
treatment of the condition that caused it plus treat- 
ment of "mild" endocarditis, as previously described, 
with the meeting of all other indications as they occur. 
As in septic processes, the nutrition must be pushed to 
the full extent to which it can be tolerated by the 
patient, namely, small amounts of a nutritious, varied 
diet, given at three-hour intervals. 

Whether milk or any other substance containing lime 
makes fibrin deposits on the ulcerative surfaces more 
likely or more profuse, and therefore emboli more 
likely to occur, is perhaps an undeterminable question. 
In instances in which hemorrhages so frequently occur, 
as they do in this form of endocarditis, calcium is 
theoretically of benefit. Quinin has not been shown to 
be of value, nor has salicylic acid, unless the cause is 
rheumatism. Alcohol has been used in large doses, as 
it has been so frequently used in all septic processes. 
If the patient is unable to take nourishment in any 
amount, small doses of alcohol may be of benefit. It 
is probably of no other value. It is doubtful whether 
ammonium carbonate tends to prevent fibrin deposits 
or clots in the heart, as so long supposed. In fact, 



380 CHRONIC ENDOCARDITIS 



whenever the nutrition is low and the patient is likely 
to have cerebral irritation from acidosis, whenever the 
kidneys are affected, or whenever a disease may tend 
to cause irirtation of the brain and convulsions, it is 
doubtful if ammonium carbonate or aromatic spirit of 
ammonia is ever indicated. Ammonium compounds 
have been shown to be a cause of cerebral irritation. 

Malignant endocarditis may prove fatal in a few 
days, or may continue in a slow subacute process for 
weeks or even months. 

Chronic Endocarditis 
It is not easy to determine when subacute endo- 
carditis becomes chronic. The process manifests itself 
by a gradual sclerosis of the valves. It should be 
treated on the same principles as the acute type, 
depending largely on the supposed cause of the disease. 

CHRONIC VALVULAR DISEASE 

As has been indicated, chronic valvular disease 
arises commonly as the result of acute or chronic endo- 
carditis, the former from infections, the latter perhaps 
associated with syphilis, alcoholism, gout, focal infec- 
tions, etc. 

The valvular disease may narrow or constrict the 
opening, giving rise to so-called stenosis; or it may 
render the valves incapable of closing correctly — 
socalled insufficiency. Because of its increased work 
the heart muscle may hypertrophy. As long as this 
hypertrophy is adequate the heart continues its work 
satisfactorily and the valvular lesion is said to be 
compensated. When the muscle is degenerated it may 
be unable to accomplish its work and is said to fail, 
and symptoms of cardiac failure appear. As the 
heart chambers overfill and are emptied with difficulty, 
dilatation takes place. 

THE COMPENSATED HEART 

As long as compensation is complete no medication 
or physical treatment is necessary. However, such a 
patient should so order his life as to throw no special 
strain on the taxed organ. Severe athletic efforts, 
rushing up and down stairs, prolonged tension, 



d, 



MITRAL STENOSIS 381 

extreme worry, are to be interdicted. Tobacco and 
alcohol, tea and coffee should not be taken. Ordinary 
diseases occurring in such patients should be treated 
with exceptional watchfulness of the circulation. 

Mitral Stenosis 

Perhaps 60 per cent, of mitral stenosis, which occurs 
most commonly between the ages of ten and thirty, 
has its origin in rheumatic endocarditis. This lesion 
is a serious handicap in such diseases as pneumonia, 
pleurisy or bronchitis, in which there is congestion 
of the lungs. 

Among the more important symptoms are a mur- 
mur, diastolic and perhaps presystolic, heard over the 
left ventricle and accentuated at the apex. Usually 
there is an accentuated pulmonary closure. The pulse 
is generally slow ; dyspnea on exertion is common and 
an increase in mucus in the throat is not infrequent. 

As weakening of the compensation occurs, the heart 
beat becomes irregular; there is venous congestion of 
the head and face, blueing of the lips and sometimes 
hemoptysis. These patients suffer more or less from 
cold extremities. 

Besides the usual treatment for broken compensa- 
tion in patients with this lesion, digitalis is of the 
greatest value, and the slowing of the heart by it, 
allowing the left ventricle to be more completely filled 
with the blood coming through the narrowed mitral 
opening during the diastole, is the object desired. 
This drug acts similarly on both the right and left 
ventricles, and though there is no real occasion for 
stimulation of the left ventricle, and it is the right 
ventricle that is in trouble, dilated and failing, still a 
greater force of left ventricle contraction helps the 
peripheral circulation. The action on the right ventricle 
contributes greatly to the relief of the patient by send- 
ing the blood through the lungs and into the left 
auricle more forcibly, and the left ventricle receives 
an increased amount of blood, the congestion in the 
lungs is relieved and the dyspnea improves. Perhaps 
there is no class of cardiac diseases in which more 
frequent striking relief can be obtained than in these 
cases of mitral stenosis. 



382 MITRAL INSUFFICIENCY 

If the congestion of the lungs is very great and 
death seems imminent from cardiac paralysis, if 
cyanosis is serious and bloody, frothy mucus is being 
expectorated, venesection and an intramuscular injec- 
tion of aseptic ergot may be indicated. Digitalis should 
also be given, hypodermatically perhaps, but its action 
would be too late if it was not aided by other more 
quickly acting drugs, such as strophanthin, intra- 
venously. The physician may often save life by such 
radical measures. 

Mitral Insufficiency: Mitral Regurgitation 

This is the most frequent form of valvular disease 
of the heart, and is due to a shortening or thickening 
of the valves, or to some adhesion which does not 
permit the valves to close properly, and the blood 
consequently regurgitates from the left ventricle into 
the left auricle during the contraction of the ventricle. 
Such regurgitation may occur without valvular disease 
if for any reason the left ventricle becomes dilated 
sufficiently to cause the valve to become insufficient. 
Such a dilatation can generally be cured by rest and 
treatment. As with mitral stenosis, the most frequent 
causes are rheumatism and chorea, which are mostly 
due to mouth infection, with the occasional other causes 
as previously enumerated. 

The characteristic murmur of this lesion is a systolic 
blow, accentuated at the apex, transmitted to the left 
of the thorax, generally heard in the back, near the 
lower end of the scapula, and transmitted upward 
over the precordia. 

Of all cardiac lesions, this is the safest one to have. 
Sudden death is unusual, the compensation of the 
heart seems to be most readily maintained, and the 
patient is not so greatly endangered by overexertion or 
by inflammations in the lungs. As in mitral stenosis, 
any increase in blood pressure — whether the normal 
increase after the age of 40, any continued earlier 
high tension, or increase from occupation or exercise — 
is serious, as causing the left ventricle to act more 
strenuously, so that more blood is forced back into 
the left auricle, the lungs become congested, and the 
right ventricle, sooner or later, becomes incompetent. 






AORTIC STENOSIS 383 

When compensation fails with these patients, the 
first sign is pendent edema of the feet, ankles and 
legs; subsequently, if there is progressive failure of 
compensation, the usual symptoms occur. 

The treatment is principlly rest and digitalis, and 
the recovery of compensation is often almost phe- 
nomenal. Patients with this lesion are likely to be 
children and young adults, and the heart muscle 
readily responds as a rule to the treatment inaugurated. 
Later, in these patients, or if the lesion occurs in older 
patients, the return to compensation does not occur 
so readily. If the condition is developed from a 
myocarditis or from fatty degeneration of the heart, 
it may be impossible to cause the left ventricle to 
improve so much as to overcome this relative dilata- 
tion or relative insufficiency of the valve. If the 
dilatation of the left ventricle is due to some poisoning, 
such as nicotin, with proper treatment — stopping the 
use of tobacco, administration of digitalis, and rest — 
the heart muscle will generally recover and the valve 
again properly close. 

Aortic Stenosis: Aortic Obstruction 

Valvular disease at the aortic orifice is much less 
common than at the mitral orifice, and while stenosis 
or obstruction is less common from rheumatism or 
acute inflammatory endocarditis than is insufficiency 
of this valve, a narrowing or at least the clinical sign 
of narrowing, denoted by a systolic blow at the base 
of the heart over the aortic opening, is in arterio- 
sclerosis and old age of frequent occurrence. If such 
narrowing occurs without aortic insufficiency at the 
age at which it usually occurs, it may not seriously 
affect the heart. It may follow acute endocarditis, 
but it most frequently follows chronic endocarditis 
or atheroma, in which the aortic valves become 
thickened and more or less rigid; this condition most 
frequently occurs in men. 

Anything that tends to increase arterial tension, as 
tobacco, lead or hard work, or anything that tends to 
cause arterial disease, as alcohol or syphilis, is often 
the cause of this lesion. 



384 AORTIC STENOSIS 

At times the edges of the valves may grow together 
from ulcerative inflammation, and the lumen thus be 
diminished in size ; or projecting vegetations may inter- 
fere with the opening of the valve and with the flow 
of blood. With such narrowing the left ventricle 
more or less rapidly hypertrophies, to overcome its 
increased work. 

The murmur caused by this lesion is a systolic one, 
either accentuated in the second intercostal space at 
the right of the sternum, or perhaps heard loudest 
just to the left of the sternum in this region. The 
murmur is also transmitted up the arteries into the 
neck, and may at times be heard in the subclavian 
arteries. It may also be transmitted downward over 
the heart. The pulse is slow, the apex of the rise of 
the sphygmographic arterial tracing is more or less 
sustained and rounded, and the rise is much less than 
normal. 

If this lesion occurs in old age, there is general 
arterial disease present and the tension and compress- 
ibility of the arteries vary, depending on how much 
they are hardened. The disturbed circulation is evi- 
denced by imperfect peripherial circulation and capil- 
lary sluggishness, with at times pendent edema of 
the feet and ankles, but, perhaps, little congestion of 
the lungs. The left ventricle being sufficient, there 
is no damming back through the left auricle to the 
lungs. The left ventricle may, however, become 
weakened, either by some sudden strain or by a 
chronic myocarditis, and relative insufficiency of the 
mitral valve may occur. The subsequent symptoms 
are typically those of loss of compensation. 

This lesion may allow a patient to live for years, 
provided no other serious disturbance of the heart 
occurs, such as myocarditis or coronary disease; but 
sooner or later, with the failing force of the blood- 
flow and the lessened aortic pressure, slight attacks 
of anemia of the brain occur, causing syncope or 
fainting. Also, sooner or later these patients have 
little cardiac pains. They begin to "sense" their hearts. 
There may not be actual anginas, but a little feeling 
of discomfort, with perhaps pains shooting up into 
the neck, or a feeling of pressure under the sternum. 



AORTIC STENOSIS 385 

Little excitements or overexertions are likely to make 
the heart attempt to contract more rapidly than it is 
able to drive the blood through the narrow orifice, 
and this alone causes cardiac discomfort and the feel- 
ing of cardiac oppression. 

It is essential, then, that these patients should not 
hasten and should not become excited; and any drug 
or stimulant that would cause cardiac excitement is 
bad for them. Nitroglycerin will do good work in 
these cases, and with high blood tension may be the 
only safe drug for the patient to have on hand. As 
soon as his attack occurs, with or without real angina 
pectoris, let him dissolve in his mouth a nitroglycerin 
tablet. If he feels faint, he will feel better the moment 
he lies down, and in this instance he may be improved 
by a cup of coffee, or a dose of caffein, camphor 
or ammonia. 

If the left ventricle becomes still weaker and shows 
signs of serious weakness, or if there is actual dilata- 
tion, the question of whether or not digitalis should 
be used is a subject for careful decision. The left 
ventricle should not be forced to act too sturdily 
against this aortic resistance. Consequently the dose 
of digitalis must be small. On the other hand, it 
frequently happens, especially in old age, that myo- 
carditis or fatty degeneration has already occurred 
before this cardiac weakness develops in the presence 
of aortic narrowing, and digitalis may not be indicated 
at all. We cannot tell how far degeneration may have 
gone, however, and small doses of digitalis used ten- 
tatively and carefully, perhaps two or three drops 
of an active tincture, two or three times a day, and 
then the drug carefully increased to a little larger 
dose to see whether improvement takes place, is the 
only way to ascertain whether digitalis can be used 
with advantage, or not. If it increases the cardiac 
pain and distress, it should not be used. Strychnin 
is then the drug that should be relied on, with such 
other general medication as is needed, combined with 
the coincident administration of nitroglycerin, which 
may also be given in conjunction with digitalis, if 
deemed advisable. Generally, however, if a heart with 
aortic stenosis needs stimulation the blood pressure is 



386 AORTIC INSUFFICIENCY 

generally none too high, although there may be arterio- 
sclerosis present. Therefore when nitroglycerin is 
indicated to lower blood pressure, digitalis is not 
usually indicated; when digitalis is indicated to aid 
the heart , nitroglycerin is generally not indicated. 
These patients must have high blood pressure to sus- 
tain perfect circulation at the base of the brain. 

Patients who have this lesion should not use tobacco 
in large amounts, or sometimes even in small amounts, 
as tobacco raises the blood pressure and thus puts 
more work on the left ventricle; in the second place, 
if the left ventricle is failing, much tobacco may hasten 
its debility. On the other hand, with a failing left 
ventricle and a long previous use of tobacco it is no 
time to prohibit its use absolutely. A failing heart 
and the sudden stoppage of tobacco may prove a 
serious combination. 

Aortic Insufficiency: Aortic Regurgitation 

This lesion, though not so common as the mitral 
lesion, is of not infrequent occurrence in children and 
young adults as a sequence of acute rheumatic endo- 
carditis. If it occurs later in life it generally is asso- 
ciated with aortic narrowing, and is a part of the 
general endarteritis and perhaps atheroma of the 
aortic. Sometimes it is caused by strenuous exertion 
apparently rupturing the valve. 

This form of valvular disease frequently ends in 
sudden death. On the other hand, it is astonishing 
how active a person may be with this really terrible 
cardiac defect. This lesion; from the frequent over- 
distention of the left ventricle, is one that often causes 
pain. While the left ventricle enlarges enormously 
to overcome the extra distention due to the blood 
entering the ventricle from both directions, the muscle 
sooner or later becomes degenerated, from poor coro- 
nary circulation. Unless the left ventricle can do its 
work well enough to maintain an adequate pressure 
of blood in the aorta, the coronary circulation is insuf- 
ficient, and chronic .myocarditis is the result. If the 
left ventricle has maintained this pressure for a long 
time, edemas are not common unless the cardiac weak- 
ness is serious and generally permanently serious ; that 
is, slight weakness, in this lesion, does not give edemas 



TRICUSPID INSUFFICIENCY 387 

as does slight loss of compensation in mitral disease, 
and unless the weakness of the ventricle is serious 
the lungs are not much affected. 

The physical sign of this lesion is the diastolic mur- 
mur, which is loudest at the base of the heart, is 
accentuated over the aortic orifice, and is transmitted 
up into the neck and the subclavians, and down over 
the heart and down the sternum with marked pulsa- 
tions of the arteries (Corrigan pulse) and often of 
some of the peripheral veins, notably of the arms and 
throat. 

If the left ventricle becomes dilated the mitral valve 
may become insufficient, when the usual lung symp- 
toms occur, with hypertrophy of the right ventricle; 
and if it fails, the usual venous symptoms of loss of 
compensation follow. This lesion not infrequently 
causes epistaxis, hemoptysis and hematemesis. 

Digitalis is always of value in these cases, but it 
should not be pushed. If a heart is slowed too much 
the regurgitation into the left ventricle is increased. 
Therefore such hearts should not be slowed to less 
than eighty beats per minute, or sudden anemia of the 
brain and sudden death may occur. These patients 
must not do hard work. 

Tricuspid Insufficiency 

This rarely, if ever, occurs alone; it is generally 
a sequence of other valvular defects, and represents 
an overworked, dilated right ventricle. It may, how- 
ever, occur from lesions of the lungs which impede 
the blood-flow through them. Such are fibroid 
changes in the lungs, emphysema, prolonged chronic 
bronchitis, the last stages of pulmonary tuberculosis, 
old neglected pleurisies with cirrhosis or fibrosis ot 
the lungs, and repeated attacks of asthma — anything, 
whether valvular defect or pulmonary circulatory dis- 
turbance, that increases the pressure ahead and the 
work of this ventricle. 

The symptoms are those of loss of compensation, 
as described under other valvular lesions. There may 
be jugular pulsation, especially evident in the external 
jugular on the left side. The liver enlarges and may 
pulsate. There are edemas, dropsies, ascites and per- 



388 PULMONARY VALVE DISTURBANCES 

haps hemorrhages. The heart is enlarged and there 
is a soft systolic blow heard at the lower end of the 
sternum. The dyspnea is sometimes very great, and 
cyanosis may be present, especially during paroxysms 
of coughing. 

This lesion of the heart is always benefited by 
digitalis, but the continuance of the improvement and 
its amount depend, of course, on the cause of the dila- 
tation of the ventricle. Strychnin is often of advan- 
tage. These patients should rarely receive vasodila- 
tors, and hot baths, overheating, overloading the 
stomach and vigorous purging should never be allowed. 
Sometimes improvement will not take place until 
ascitic or pleuritic fluid, if present, has been removed. 

Tricuspid Stenosis: Tricuspid Obstruction 
This is rare and probably always congenital, and is 
supposed to be due to an inflammation of the endo- 
cardium during intra-uterine life. In early childhood 
it is possible that it may be associated with left-side 
endocarditis. 

A special treatment of the heart would not be indi- 
cated unless there is associated tricuspid insufficiency, 
when digitalis might be used. 

Pulmonary Insufficiency: Pulmonary Regurgitation 

If this rare condition occurs, it is probably congeni- 
tal. A distinctive murmur of this insufficiency would 
be diastolic and accentuated in the second intercostal 
space on the left of the sternum. It should be remem- 
bered that aortic murmurs are often more plainly 
heard at the left of the sternum. Sooner or later, if 
this lesion is actually present, the right ventricle dilates 
and cyanosis and dyspnea occur. Digitalis would then 
be indicated. 



Pulmonary Stenosis: Pulmonary Obstruction 

If stenosis is actually present in this location, the 
lesion is probably congenital. It might occur after a 
serious acute infectious endocarditis, but then it would 
be associated with other lesions of the heart. It has 
been found to be associated with such congenital 
lesions of the heart as an open foramen ovale or fora- 
men Botalli, or with an imperfect ventricular septum, 



I 



ACUTE HEART ATTACK 389 

and perhaps with tricuspid stenosis — in short, a cardiac 
congenital defect. The right ventricle becomes hyper- 
trophied, if the child lives to overcome the obstruction. 

The physical sign is a systolic blow at the second 
intercostal space on the left; but, as just stated, such a 
murmur must surely be dissociated from an aortic 
murmur if found to develop after babyhood, and it 
should also be diagnosed from the frequently occurring 
hemic, basic systolic murmurs ; that is, if signs of 
pulmonary lesions are not heard soon after birth or in 
early babyhood, the diagnosis of pulmonary defects can 
be made only by exclusion. 

Unless the right ventricle is found later to be in 
trouble, there is no treatment for this condition. If 
the right ventricle dilates, digitalis may be of benefit. 

ACUTE HEART ATTACK 

The patient with valvular disease may suddenly be 
seized with an acute attack of agony in the heart 
region, dyspnea, and a feeling of oppression. A 
patient in this condition may die at any moment. 

The immediate conditions to be met are the rapid 
fluttering heart, the nervous excitation and the vaso- 
motor spasm, as well as the cardiac anxiety. Two far- 
tors of great importance are the establishment of self- 
control and confidence by the patient and the spon- 
taneous relaxation following exhaustion. The part 
played by the nervous system in such attacks is shown 
by the good effects which may follow a hypodermic 
injection of morphin sulphate. It quiets the nervous 
system, causes drowsiness, relaxes spasm, and thus 
causes increased peripheral circulation. While morphin 
is indicated, a very large dose should not be given lest 
the activity of the respiratory center be greatly 
impaired. The addition of atropin to the morphin 
may prevent the depression and sometimes of itself 
quiets cardiac pain. It may, however, irritate the heart 
and will increase vasomotor tension. The patient 
should be put to bed and recline on several pillows. 
For quick momentary stimulation smelling salts of 
ammonia may be used. If available give one half 
a teaspoonful of aromatic spirits of ammonia in 
twice the amount of water. Strychnin sulphate, 0.002 



390 BROKEN COMPENSATION 

gm., or 1/30 grain, may be given hypodermically as a 
stimulant to the central nervous system and to the 
cardiac nerves. Hot coffee may be given by the mouth. 
If available an injection of the contents of an ampule 
of camphor in oil may be injected intramuscularly. 
Epinephrin may be given in a dose of 5 drops on the 
tongue, and may be repeated in half an hour if advis- 
able. It is understood that these are merely suggested 
as alternative methods of treatment. The response of 
the patient should be carefully noted. 

If the patient collapses, with marked dyspnea, sub- 
normal blood pressure, cyanosis, feeble pulse, etc., and 
does not have the tension of fear, the treatment should 
be somewhat different. Aseptic ergot may be injected 
at once intramuscularly. If the patient has not been 
overpowered with digitalis it may be advisable to 
administer some form of this drug to obtain the future 
continued action. 

Strophanthin may be given intravenously and in this 
way is a quickly acting stimulant. The dosage should 
be from 1/500 to 1/200 grain. It should not be given 
if the patient has received much digitalis. 

If the emergency is excessively urgent, the lungs 
filled up with blood, moist rales beginning to occur, 
and frothy and blood-tinged sputum being coughed up, 
venesection may be done. If there is extreme air hun- 
ger the administration of oxygen as described by 
Meltzer aids to satisfy this need. 

Alcohol is absolutely contraindicated in these cases. 

BROKEN COMPENSATION 

Rest in bed, in a bedroom that is attractive, with 
fresh air and sunlight, is of great importance. In 
patients over 50 it may be a question as to whether 
some exercise should not be advised. The patient 
should be individualized and proper measures taken to 
give mental and physical rest, to prevent excitement, 
and at the same time to prevent mental depression. 

DIET 

The diet should be adequate ; not profuse, not defi- 
cient. Large quantities of fluids cause discomfort. 
The diet should be sufficiently varied to encourage 



TREATMENT OF BROKEN COMPENSATION 391 

appetite. In case there is dropsy or any accumulaton 
of fluid, the intake of fluids may be greatly restricted 
and only a moderate quantity of salt should be 
included in the diet. 

ELIMINATION 

The eliminative organs should usually be encouraged 
but this should not be drastic. Hot sponge baths and 
warm alcohol rubs may be given, accompanied by gentle 
massage. Diuretics generally act unsatisfactorily in 
cardiac conditions. If the secretion of urine suddenly 
becomes small in amount, the diet should be quickly 
reduced and the elimination through the skin watch- 
fully encouraged. The bowels should move satisfac- 
torily daily. Active watery purgings are rarely 
advisable and simple vegetable laxatives are usually 
sufficient. 

TREATMENT WITH CARDIAC DRUGS 

Digitalis, or some of its preparations, is the drug 
of chief reliance in this condition, dependent, of course, 
on the amount of good heart muscle available for 
it to act on. It is advisable to use a tincture of known 
character beginning with a moderate dose, perhaps 
10 drops every eight hours, and increasing a few days 
later to 15 drops once in twelve hours and later to 20 
drops once a day. The action in large doses is cumu- 
lative and with large doses the drug should not be con- 
tinued longer than five or six days without intermission. 
A number of special preparations of digitalis are 
described in New and Nonofficial Remedies. Digitalis 
or its preparations should not be u§ed when there is 
a fatty degeneration of the heart ; it should ordinarily 
not be used if there is arteriosclerosis or coronary 
disease. The signs of overaction of digitalis are 
nausea, vomiting, a diminished amount of urine, 
occipital headache, and coldness of the hands and feet. 
The pulse may be reduced to sixty or less a minute. 

In such instances the drug should be stopped imme- 
diately, saline laxatives may be given, hot sponge baths 
and perhaps alcohol or nitroglycerin. 

Strophanthus is a drug of little value in restoring 
compensation, but strophanthin intravenously or sub- 



392 CONVALESCENCE IN HEART DISEASE 

cutaneously acts quickly, stimulating the heart and 
contracting the blood vessels. 

Caffein, given as coffee or citrated caffein, iy 2 
grains two or three times early in the day, acts as a 
stimulotonic to the heart, increasing its activity. It 
is contraindicated in the presence of good compensa- 
tion. It is a cerebral stimulant. Strychnin promotes 
all muscular activity and is a general nervous stimu- 
lant. It may be indicated when the heart is acting 
sluggishly. 

CONVALESCENCE 

When compensation has been restored, the patient 
may be allowed gradually to resume his usual habits 
and work, provided that these habits are sensible, and 
that the work is not one requiring severe muscular 
exertion. Careful rules and regulations must be .laid 
down for him, depending on his age and the condition 
of his arteries, kidneys and heart muscle. It should 
be remembered that a patient over 40, who has had 
broken compensation, is always in more danger of a 
recurrence of this dilatation of the heart than one who 
is younger, as after 40 the blood pressure normally 
increases in all persons, and this normal increase may 
be just too much for a compensating heart which is 
overcoming all of the handicap that it can withstand. 
Such patients, then, should be more carefully restricted 
in their habits of life, and also should have longer and 
more frequent periods of rest. 

The avoidance of all sudden exertion in any instance 
in which compensation has just been restored is too 
important not to be frequently repeated. The child 
must be prevented from hard playing, even running 
with other children, to say nothing of bicycle riding, 
tennis playing, baseball, football, rowing, etc. The 
older boy and girl may need to be restricted in their 
athletic pleasures, and dancing should often be pro- 
hibited. Young adults may generally, little by little, 
assume most of their ordinary habits of life; but 
carrying heavy weights up-stairs, going up more than 
one flight of stairs rapidly, hastening or running on 
the < street for any purpose, and exertion, especially 
after eating a large meal, must all be prohibited. 
Graded physical exercise or athletic work, however, is 






CONVALESCENCE IN HEART DISEASE 393 

essential for the patient's future health : at first walk- 
ing and later more energetic exercise may be advisable. 

These patients must not become chilled, as they are 
likely to catch cold, and a cold with them must not 
be neglected, as coughing or lung congestions are 
always more serious in valvular disease. Their feet 
and hands, which are often cold, should be properly 
clothed to keep them warm. Chilling of the extremities 
drives the blood to the interior of the body, increases 
congestion there, and by peripheral contraction raises 
the general blood pressure. A weak heart generally 
needs the blood pressure strengthened, but a compen- 
sating heart rarely needs an increase in peripheral 
blood pressure, and any great increase from any 
reason is a disadvantage to such a heart. The patient 
should sleep in a well-ventilated room, but should not 
suffer the severe exposures that are advocated for 
pulmonary tuberculosis, as severe chilling of the body 
must be absolutely avoided. 

The peripheral circulation is improved, the skin is 
kept healthy, the general circulation is equalized, and 
the heart is relieved by a proper frequency of warm 
baths. Cold baths are generally inadvisable, whether 
the plunge, shower or sponging; very hot baths are 
inadvisable, on account of causing faintness; while 
warm baths are not stimulating and are sedative. The 
Turkish and Russian baths should be prohibited ; they 
are never advisable in cardiac disease. With kidney 
insufficiency, body hot-air treatment (body-baking), 
carefully supervised, may greatly benefit a patient who 
has no dilatation of the heart and who has no serious 
broken compensation. Surf-bathing and, generally, 
sea-bathing and lake-bathing are not advisable. The 
artificial sea-salt baths and carbon dioxid baths may 
do some good, but they do not lower the general blood 
pressure so surely as has been claimed, and probably 
no great advantage is derived from such baths. If a 
patient cannot properly exercise, massage should be 
given him intermittently. 

Any systemic need should be supplied. If the patient 
is anemic, he should receive iron. If he has no appe- 
tite, it should be encouraged by bitter tonics. If sleep 
does not come naturally, it must be induced by such 
means as do not injure the heart. 



394 TREATMENT OF ANGINA PECTORIS 

ANGINA PECTORIS 

Angina pectoris is a name applied to the condition 
manifested by pain in the heart region, due to the 
heart itself. 

SYMPTOMS 

The pain of the true angina pectoris generally starts 
in the region of the heart, radiates up around the left 
chest, into the shoulder, and often down the left arm. 
Such a patient is likely to assume a characteristic 
posture. He stops still wherever he is, stands per- 
fectly erect or bends his body backward, raises his 
chin, supports himself with one hand and places the 
other over the heart. The duration of the attack is 
usually but a few seconds, but the patient may die in 
the first or in any subsequent attack. The pulse may 
become very slow. Profuse sweating, restlessness and 
dyspnea may accompany an attack. The pain may be 
felt especially in the upper part of the sternum over 
the aorta. 

IMMEDIATE TREATMENT 

For treatment of the immediate pain, anything may 
be given that quickly relieves local or general arterial 
spasm and spasm of the muscles. The moment that 
the heart and its arterioles relax, the attack is often 
over. The most quickly acting drug for this purpose 
is amyl nitrite, inhaled. If amyl nitrite is not at hand, 
or has been found previously to cause considerable 
disturbance of the head or a feeling of prolonged 
faintness, nitroglycerin is the next most rapidly acting 
drug. It may be given hypodermatically, or a tablet 
may be dissolved under the tongue. The amyl nitrite 
should be in the emergency case of every physician, in 
the form of ampules, or may be carried by the patient 
after he has had one attack. The ampules now come 
made of very thin glass with an absorbent and silk 
covering ready for crushing with the fingers, and are 
thus immediately ready for inhalation. One of these 
is generally all that it is necessary to use at any one 
time. Nitroglycerin may be given hypodermatically in 
a dose of 1/100 grain. If given by mouth the dose 
should be the same, repeated in ten minutes if the pain 
has not stopped. 



TREATMENT OF ANGINA PECTORIS 395 

Almost coincidently with the administration of nitro- 
glycerin or the amyl nitrite a hypodermatic injection 
of 1/8 or 1/6 grain of morphin sulphate should be 
given without atropin, as full relaxation is desired 
without any stimulation of atropin. 

If the patient is at home and at rest at the time of an 
attack, a hot-water bag but slightly filled, or a pad 
electrically heated may be placed over the heart, some- 
times with marked advantage and relief from pain. 
Occasionally even such gentle applications are not 
tolerated. 

After the attack is over absolute rest for some 
hours, at least, is positively necessary. If the attack 
was severe, the patient should rest several days, as 
there seems to be a great tendency for such attacks 
to come in groups, the cause being acutely present 
for at least some time. But little food should be 
given; nothing very hot or very cold, and no large 
amount of liquids; gentle catharsis may be induced 
on the following day, if deemed advisable; no stimu- 
lating drugs should be administered, and nothing that 
would raise the blood pressure. 

The question often arises as to whether the patient 
shall be told of the consequences of his condition. It is 
hardly wise to withhold this knowledge from him, 
and generally it is not necessary. The ordinary alert 
patient knows how serious the condition is by his own 
feelings, and will even reprove or joke with his physi- 
cian for minimizing the danger. It is best that the 
whole subject be discussed carefully with him and his 
life regulated and ordered, and emergency drugs pre- 
pared and given him with proper instructions to the 
family, so that he may possibly prevent other attacks, 
and, if they occur, may have the best immediate 
treatment. 

PREVENTION 

To prevent the attacks it is of first importance that 
the patient live a regular life, and avoid overexertion, 
mental excitement, chilling of the body and anything 
else that seems to bring on the pains. Moderation in 
the diet, especially in the obese, should be the rule. 
Rest and diversion with graduated exercises are the 
greatest factors in the beneficial results of baths of 



396 AURICULAR FIBRILLATION 

the type given at Nauheim and other institutions. 
Essentially the same baths may be given at home by 
adding 9 pounds of sea-salt and 10 ounces of com- 
mercial calcium chlorid to 40 gallons of water, with 
or without carbonic acid gas. 

The acute symptoms being over, a careful analysis 
of the probable cause of the anginal attack should be 
made. If there is a general sclerosis, the treatment 
should be directed to that condition. If there is a 
myocarditis or a fatty heart, this should be treated as 
previously described. If there is a toxemia from 
intestinal disturbance, that may readily be remedied. 
If the cause is nicotin, it need not again occur from 
that reason, and perhaps the damage caused by the 
nicotin may be removed. Any organic kidney trouble 
must, of course, be managed according to its serious- 
ness; and, if there is hypertension, treatment should 
be directed toward its relief. And especially inquiry 
should be made as to the possibility of syphilis being 
a factor. 

AURICULAR FIBRILLATION 

While auricular fibrillation is a clinical entity, it 
is often difficult of diagnosis, and sometimes can be 
excluded only by treatment and the results of treat- 
ment, or by watching the patient for some time. When 
completely present, it consists really of a paralysis of 
the auricles; normal systolic contractions of the 
auricles do not occur, although there are little rapid 
twitchings of different muscle fibers of the auricles, 
which give the name to the condition. 

The irregular pulse in articular fibrillation is more 
or less distinctive, being generally rapid, from 110 
upward. Occasionally the pulse-rate may be much 
slower, if the heart is under the influence of digitalis. 
The irregularity of the pulse in this condition is 
excessive; the rate, strength and apparent intermit- 
tency during a half minute may not at all represent 
the condition in the next half minute, or in the next 
several minutes. It has been thought that auricular 
fibrillation, while prevented many times by digitalis, 
is perhaps incurable. This is probably not true in 
the early stages of the condition. If digitalis does not 



INCIDENCE OF AURICULAR FIBRILLATION 397 

cure the irregularity, the condition has been termed the 
"absolutely irregular heart." Other terms applied to 
the condition have been "ventricular rhythm," "nodal 
rhythm" and "rhythm of auricular paralysis." The 
condition of the pulse has been Latinized as pulsus 
irregularis perpetuus. 

While the condition is best diagnosed by tracings 
taken simultaneously of the heart, jugular and radial, 
still the jugular tracing is almost conclusive in the 
absence of the auricular systolic wave. The radial 
tracing is exceedingly suggestive, and if it is taken 
with a careful stethoscoping of the heart, an almost 
certain presumptive diagnosis may be made. 

OCCURRENCE 

This condition of auricular fibrillation occurs occa- 
sionally in valvular disease, and perhaps most fre- 
quently in mitral stenosis; but it can occur without 
valvular lesions, and with any valvular lesion. If it 
occurs in younger patients, valvular disease is likely 
to be a cause; if in older patients, sclerosis or myo- 
cardial degeneration is generally present. 

It may also follow depressing infections, such as 
diphtheria, or some infection that has caused a myo- 
carditis. Rarely this fibrillation may be caused by 
some of the drugs used to stimulate the heart. 

It is astonishing how few symptoms may be 
present in auricular fibrillation and with an absolutely 
irregular heart action. The patient may be able to 
perform all of his duties, however strenuous, until 
coincident, concomitant or causative ventricular weak- 
ening and dilatation or broken compensation occurs, 
and then the symptoms are those due to the cardiac 
failure. Often in the first stage of this weakening 
and later fibrillation of the auricles the patient may 
recognize the cardiac irregularity and disturbances. 
Generally, however, he soon becomes accustomed to 
the sensations, and, unless he has cardiac pains or 
dyspnea, he becomes oblivious to the irregularity. At 
other times he may be conscious of irregular, strong 
throbs or pulsations of the heart, as such hearts often 
give an occasional extra sturdy ventricular contraction. 
These he notes. Real attacks of tachycardia may be 



398 TREATMENT OF AURICULAR FIBRILLATION 

superimposed on the condition. Sooner or later, how- 
ever, if the condition is not stopped, cardiac weakness 
and loss of compensation, with all the usual symptoms, 
occur. It seems to be probable that more than half 
of all cases of heart failure are due to aricular fibril- 
lation, or at least are aggravated by it. 

TREATMENT 

The condition may be stopped by relieving the heart 
and circulation of all possible toxins and irritants, and 
by the administration of digitalis. One attack is fre- 
quently followed by others, perhaps of longer dura- 
tion. Occasionally, however, the patient may be 
observed for many years without the condition again 
occurring. If the pulse, in spite of treatment, is 
permanently irregular, and auricular insufficiency is 
permanent, the patient is of course in danger of cardiac 
failure; but still he may live for years and die of 
some other cause than heart failure. The prognosis 
seems to be better when the pulse is not rapid — below 
a hundred. This shows that the ventricles are not 
much excited and do not tend to wear themselves out. 

Any treatment that lowers the heart- rate is of advan- 
tage, such as the stopping of tea and coffee, the admin- 
istration of digitalis, and an increased amount of rest 
and quiet. Digitalis should be increased gradually 
until a fair dose is given, and it is better to administer 
one dose a day than several. If it causes undesired 
symptoms, such as cardiac pain, a tight feeling in the 
chest, nausea or vomiting, or a diminished amount of 
urine, it is not acting well and should be stopped. If 
the pulse is gradually slowed to about what is normal, 
its action should be considered successful. 

If the pulse is intermittent and there is apparently 
a heart-block, Stokes-Adams disease should be con- 
sidered as possibly present, and digitalis would be 
contraindicated and would do harm. 

A scientific indication as to whether a heart is dis- 
turbed through the action of the vagi nerves or whether 
the disturbance is due to muscle degeneration may be 
obtained by the administration of atropin. Talley 
(Amer. Jour. Med. Sci., Oct., 1912) of Philadelphia 
shows the diagnostic value of this drug. It is a familiar 



TREATMENT OF AURICULAR FIBRILLATION 399 

physiologic fact that stimulation of the vagi slows the 
heart or even stops it. Stimulation of these nerves 
by the electric current, however, does not destroy the 
irritability of the heart; indeed, the heart may act by 
local stimulation after it has been stopped by pneumo- 
gastric stimulation. It is also a well known fact that 
anything that inhibits or removes vagus control of the 
heart allows the heart to become more rapid, since 
these nerves act as a governor on the heart's contrac- 
tion. Under the influence of atropin the heart- rate 
is increased by paralysis of the vagi. Talley states 
that a hypodermic injection of from 1/50 to 1/25 grain 
of atropin produces the same paralytic and rapid heart 
effect in man. He advises the use of 1/25 grain of 
atropin in robust males, and 1/50 grain in females 
and in less robust males, and he has seen no serious 
trouble occur from such injections. The throat is, of 
course, dry and the eyesight interfered with for a 
day or more, but Talley has not seen even insomnia 
occur, to say nothing of nervous excitation or delirium. 
Theoretically, however, before such atropin dosage, a 
possible idiosyncrasy against belladonna should be 
determined. 

The value of this test rests on the fact that 
atropin thus injected will increase the normal heart 
from thirty to forty beats a minute, and Talley 
believes that if the heart-beat is increased only, twenty 
or less, if the patient has not been suffering from an 
exhausting disease, it shows "a degenerative process 
in the cardiac tissue, which makes the outlook for 
improvement under treatment unpromising." He 
also believes that when the heart-beat in auricular fibril- 
lation is increased the normal amount or more than 
normal, the prognosis is good. He still further advises 
in auricular fibrillation an injection of atropin before 
digitalis has been administered, and another after 
digitalis is thoroughly acting. Comparison of the find- 
ings after these two injections will determine which 
factor, vagal or cardiac tissue, is the greater in the 
condition present. The patients with a large cardiac 
factor are the ones who may be more improved by the 
digitalis treatment than those in whom the fibrillation 
is caused by vagus disturbance. 



400 TREATMENT OF HEART BLOCK 

HEART BLOCK 

Complete heart block is due to pathologic changes 
affecting the system of fibers whose function it is to 
convey from the auricles the stimulus which causes 
normal ventricular contraction. Gummas, calcified 
plaques, or tumors may press on or invade that part 
of the auriculoventricular conducting system known 
as the bundle of His. Fibrosis, fatty degeneration, 
infarcts and inflammatory changes occurring in the 
bundle of His and perhaps other portions of the con- 
ducting system, may also produce heart block. Incom- 
plete heart block, in which the relation of auricular 
to ventricular rhythm is partially retained, may be due 
to less extensive changes in the auriculoventricular 
system, resulting from acute infections such as pneu- 
monia, diphtheria, rheumatism, typhoid fever or sepsis ; 
from lesions of the medulla oblongata or vagus, and 
from overdosage with digitalis. It is probable that 
many deaths in acute infections are due to some form 
of heart block, and are caused by inflammatory swell- 
ing of the fibers of the auriculoventricular system. 

Patients with heart block may present no symptoms 
except slow pulse and independent rhythm of auricles 
and ventricles. This difference in rhythm is deter- 
mined by comparing the number of pulsations of the 
jugular veins per minute as observed in the neck, 
with the radial pulse or the ventricular beat as made 
out at the heart. Syncopal attacks, completing the pic- 
ture of the Adams-Stokes syndrome, may occur at 
the onset of complete heart block or at any time after 
this condition has become established. 

If durjng a syncopal attack, the ventricles remain 
inactive for from fifteen to twenty seconds, muscular 
twitchings simulating an epileptiform seizure occur. 
If the ventricles are inactive for much longer than 
twenty seconds, death results. In some cases of com- 
plete heart block in which the ventricles beat with their 
own slow rhythm, independently of the auricles, the 
syncopal attacks may be absent for many years. 

TREATMENT 

Antisyphilitic treatment will greatly improve or cure 
those cases of heart block which are syphilitic in 



TREATMENT OF HEART BLOCK 401 

origin, in which the conducting system has not been 
completely destroyed. A Wassermann test should, 
therefore, always be made. In cases due to other 
causes, drug treatment offers relatively little help. 
Digitalis, since it tends to slow still further the ven- 
tricular rate, should be withheld except in cases of 
long standing which have become decompensated owing 
to myocardial disease. Atropin may be used in the 
attack, but many who have given special study to the 
action of drugs in these cases question its value. Rest 
is important especially in the cases occurring during 
acute infections. 



DISTURBANCES OF THE BLOOD 
AND BLOOD-MAKING ORGANS 



ANEMIA 






In the conditions characterized by a reduction of the 
oxidizing power of the blood we distinguish two prin- 
cipal varieties. In one of these the corpuscles are only 
moderately affected, but are less efficient oxidizing 
agents because they contain a deficient amount of 
hemoglobin. The number of red cells is only moder- 
ately reduced, but the functional power of each cell 
is far below the normal. The blood when examined by 
laboratory methods is found to have a low color index. 
To determine this it is necessary to estimate the num- 
ber of red corpuscles in a cubic millimeter. This fig- 
ure is then compared with 5,000,000, the average num- 
ber of red corpuscles in a cubic millimeter of blood 
of a normal person, the result representing the per- 
centage of corpuscles. This percentage is made the 
denominator and the percentage of hemoglobin the 
numerator, and the resulting fraction is the color index. 

In chlorosis and secondary anemias the color index 
is low; in pernicious anemia the color index is high, 
although the total amount of hemoglobin is much 
reduced. In pernicious anemia many corpuscles have 
been destroyed but the individual corpuscle carries 
more than the average charge of hemoglobin. Having 
fixed the type of anemia, it is necessary to search for 
any etiologic factor which may favor the reduction of 
the corpuscles or make them poor in hemoglobin. Any 
loss of blood if often repeated or habitual is likely to 
lead to anemia or may so act on the blood-fnaking 
organs as to transform the type of the disease into the 
pernicious form. Care should be taken to exclude 
wasting of cachectic diseases, which frequently lead to 
secondary anemias which may be incurable, until the 
primary affection is removed. Intestinal worms, par- 
ticularly hookworm and tapeworm, frequently cause 
anemia, partly by the repeated drawing of blood and 



TREATMENT OF ANEMIA 403 

partly by the toxins produced by the worm and 
absorbed into the bloodstream. Other poisons, either 
extraneous or autogenous, may produce a like effect, 
especially the products of mouth infection. 

TREATMENT 

The first step in treatment after removing any dis- 
coverable cause is to place the patient under the best 
hygienic conditions and afford as nourishing a diet as 
possible. 

In combating the anemia, of greatest importance is 
the improvement of the hygienic condition of the 
patient, by fresh air, sunlight, and moderate exercise. 



DIET 

The chief point as regards diet is the necessity of 
increasing the amount of meat, which contains two to 
eight times more iron than such foods as rice and other 
farinaceous foods. The following table gives the per- 
centages of iron in various food substances : 

Contains 
100 Gm. Mg. of Iron 

Rice 1.8 

Rye 4.9 

Wheat 5.3 

Oats 13.1 

Corn 3.6 

Potatoes 42 

Peas 6.6 

Beans . . . i 7.5 

Apples 132 

Strawberries 8.9 

Cabbage 3.9 

Spinach 35.9 

Milk 2.3 

Beef 4.8-16.6 

Eggs 5.7 

Fish 1.5-84.2 

Veal 2.7 

The diet should therefore contain much animal food, 
beef, mutton or chicken, etc. Food may be taken in 
smaller amount and at more frequent intervals. 



404 TREATMENT OF CHLOROSIS 

There can be no question of the advantages of fresh 
air and sunlight to patients suffering from anemia, and 
there could be no better treatment than the open-air 
sanatorium treatment advocated for tuberculosis for 
these anemic patients. Patients improve with iron, and 
they will improve as much with an inorganic iron as 
with any organic iron. The mistake has been that too 
much iron is administered, hence some peptonate or 
albuminate or other organic iron has been said to be 
better tolerated. The mistake has been that the dose 
of the inorganic iron was not small enough ; very little 
is needed to satisfy the economy for iron. The tincture 
of the chlorid of iron, or the reduced iron in tablet or 
capsule, or the pill of the carbonate of iron (Blaud), 
or the saccharated oxid of iron present a variety of 
inorganic irons sufficient to meet any indication; the 
multitude of other iron preparations is not needed and 
is superfluous. Moreover, as iron is used in chronic 
conditions over a long period of time, it is irrational 
to give it intravenously. 

DETAILS OF TREATMENT IN CHLOROSIS 

In chlorosis, so generally accompanied as it is with 
amenorrhea, thyroid substance may be given in small 
doses, as : 

Gm. 

f£ Thyroidei sicci 3\ or gr.xlv 

M. et fac capsulas 20 (dry). 

Sig. : One capsule, three times a day, after meals. 

Or: 

Gm. 

H Thyroidei sicci 2| 

Ferri reducti.. 2| or aagr.xxx 

M. et fac capsulas 20 (dry). 

Sig. : One capsule, three times a day, after meals. 

Occasionally cases of chlorosis resist iron and 
improve only after they have been kept in bed for a 
number of weeks. In some of these recovery is 
hastened by arsenic. 

In convalescence from chlorosis iron should be con-, 
tinued in small doses for from three to six months. 



PERNICIOUS ANEMIA 405 

Iron may be given as follows : 



Gm. 



R Tincture ferri chloridi 5 

Syrupi acidi citrici '25 

Aquae ad 100 

M. Sig.: A teaspoonful, in water, three times a day, after 
meals. 



A3 iss 

or flSi 
ad A3 iv 



Or: 

Gm. 

$ Ferri reducti 2| or gr.xxx 

M. et fac capsulas 20 (dry). 

Sig. : One capsule, three times a day, after meals. 

Or: 

R Pilulas ferri carbonatis. (Blaud) No. 20. 
Sig. : One pill, three times a day, after meals. 

PERNICIOUS ANEMIA 

Several conditions have been included under this 
name, but the most frequent cause is probably focal 
infection. It should include cases with the following 
symptomatology: It is commonest in people of mid- 
dle age; the well to do are affected almost as 
often as the poor; men and women are affected 
in approximately equal numbers ; the onset is, as a 
rule, insidious, tfre patients complaining of weak- 
ness without apparent cause, of increasing pallor 
(with straw-colored tint to the skin) ; of dyspnea, of 
gastro-intestinal disturbances, and of nervous symp- 
toms; the urine is usually highly colored and con- 
tains a high amount of urobilin ; there is always gastric 
anacidity, and the blood changes characteristic of a 
hemolytic anemia are demonstrable (reduced red 
count ; anisocytosis ; poikilocytosis ; high color index ; 
often regeneration signs, including nucleated red cells, 
polychromasic red cells and basophilic stippling; mod- 
erate leukopenia with relative lymphocyte increase, 
and a diminished number of platelets). There is often 
a little fever but not always. Numbness in the hands 
and feet are not uncommon; in the later stages the 
anesthesias, paralyses or ataxias due to lesions in the 
spinal cord may be encountered. 

The primary treatment is to seek and remove focal 
infection, frequently in the mouth. The treatment of 



406 TRANSFUSION IN PERNICIOUS ANEMIA 

pernicious anemia in general must be conducted 
on the same principles as govern simple anemia, 
except that it is generally recognized that iron is 
practically useless in this form of the disease. There 
is no deficiency in iron in pernicious anemia, but with 
repeated courses of arsenic it is possible sometimes to 
keep patients in good condition for years, even some- 
times retaining their earning capacity. The patient 
should be kept under constant supervision, so that 
the arsenic can be promptly resumed at the first signs 
of a relapse; iron may then prove useful also when 
the arsenic fails. In pernicious anemia, hydrochloric 
acid and pepsin must be given persistently. 

SPLENECTOMY 

For some time it was believed that splenectomy, 
which was frequently followed by immediate improve- 
ment, was a measure of much promise in this disease. 
The present belief is that the results achieved do not 
warrant the use of this radical measure. 

ARSENIC 

In giving arsenic for this disease Cabot advises to 
begin with a dose of two minims of Fowler's solution 
(liquor potassii arsenitis), well diluted, three times a 
day, after meals, and gradually increase until the patient 
is taking 15 minims three times daily. The drug may 
be given in soluble tablet form, commencing with .002 
gm. (1/30 grain) and increasing according to the 
patient's tolerance. When symptoms of intolerance 
appear the medicine should be suspended until the 
symptoms disappear when the treatment should be 
resumed. In Cabot's experience atoxyl, sodium caco- 
dylate, and similar preparations present no advantage 
over the ordinary forms of arsenic. 

BLOOD TRANSFUSION 

Blood transfusion has been given an extended trial 
in this condition, but also without permanent cures. 

Anders (Amer. Jour. Med. Sal, 158:659, 1919) 
maintains that blood transfusion offers more for this 
disease than any other form of treatment. More than 






TREATMENT OF PERNICIOUS ANEMIA 407 

half of some 450 cases treated by this method showed 
an initiation of remissions. Repeated small transfu- 
sions of from 200 to 500 c.c. of blood gave more satis- 
factory results than single massive ones. 

GENERAL TREATMENT 

The general treatment of this condition includes 
dietetic and hygienic measures, pharmacotherapy, com- 
bating of focal, gastric and intestinal sepsis. 

Barker and Sprunt describe the regimen for these 
patients as conducted by them in the Johns Hopkins 
Hospital. A diagnostic study of the patient is made. 
He is placed in bed in a private room and given abso- 
lute rest. After the history has been carefully inves- 
tigated and the usual complete examination of the blood 
and the secretions made, a thorough search is made 
for possible focal infection. The mouth, nose and 
throat, sinuses, digestive tract and urogenital tract 
are carefully investigated by specialists If any focal 
infection is found it should be thoroughly eradicated. 

The dietetic treatment is elaborate. In the severer 
cases they begin with the milk diet of Dubois. On 
the first day 2^ ounces of milk are given every two 
hours from 7 a. m. to 9 p. m. and this two hourly 
quantity is increased each day until, the sixth day, the 
patient is receiving some 3 quarts. On the seventh day 
a small piece of bread and a little jelly, fruit or pre- 
serves at breakfast time are permitted and at midday 
a full tray of easily digestible foods. The patient is 
encouraged to eat regardless of choice or inclination 
and to empty each dish on his tray. The portions are 
gradually increased until the patient is receiving an 
abundant diet. 

At this time the patient is given an egg, soft boiled, 
poached or raw, with a little orange juice immediately 
after each of the three meals. Later on, two eggs are 
given. Extra milk is also given between meals. Many 
patients may, within two or three weeks, be induced to 
take six raw eggs, a quart and a half of milk and a pint 
of cream each day, in addition to three full meals. The 
daily dietary may thus reach an intake of 4000 to 5000 
calories. The patient soon learns to take an interest 



408 TREATMENT OF PERNICIOUS ANEMIA 

in watching the increase in weight and the coincident 
increase in red corpuscles and hemoglobin. 

The pharmacotherapy is chiefly given in order to 
build up satisfactorily the patient's nutrition. On 
account of the gastric anacidity 20 to 30 drops of 
hydrochloric acid, dilute, with or without pepsin given 
with each meal and the same dose repeated one-half 
hour after each meal is recommended by Barker. This 
dosage is perhaps somewhat too large. In addition 
pancreatin, 45 grains, with calcium carbonate, 45 grains, 
is given three hours after each meal. A bitter tonic ( 10 
minims of tincture of nux vomica in 1 dram of com- 
pound tincture of gentian) given ten or fifteen min- 
utes before each meal may do something toward 
improving the appetite. This dosage also seems some- 
what large and a smaller dosage or any other simple 
bitter would probably serve the purpose. With all 
this should go an encouraging psychotherapy, to over- 
come the extreme depression of these patients. 

Of late, Barker and Sprunt have given arsenic in 
the form of sodium cacodylate, intramuscularly, 50 
mg. per dose, once daily for eight days, and after 
an interval of two weeks a second course of eight 
injections. Cabot, and many others, as mentioned, do 
not find that the cacodylate has any advantages over 
the ordinary Fowler's solution. 

The patient remains quietly in bed until the hemo- 
globin is above 60 per cent, and he then begins quiet 
resistive movement exercises. Rest in bed is main- 
tained until the hemoglobin percentage is above 80 
and the red corpuscle count above 4,000,000. Con- 
valescence is then carried on very slowly. When 
the patient leaves the hospital he is warned to continue 
the hydrochloric acid treatment to overcome the per- 
manent gastric anacidity and is also instructed in proper 
diet. 

In cases where the blood count and hemoglobin 
were very low before starting the treatment, blood 
transfusion has been given to bring these up to a 
higher level. 

The remarkable features of this disease are the rapid, 
extensive, severe and pernicious character of the blood 



LEUKEMIA 409 

destruction and the no less striking powers of recovery 
under a good regimen when the hemolysis is halted. 
These powers of recovery should not lead the physician 
either to become doubtful of his original diagnosis or to 
believe in and to give too favorable a prognosis. 
Within even comparatively short periods of time the 
patient may suffer a relapse more serious than the 
original attack and not infrequently fatal. 

LEUKEMIA 

This mysterious disease, whose cause is not yet 
accurately determined, is characterized by a persistent 
increase in the white blood corpuscles. Two forms 
are known, the splenomyelogenous, in which there is 
enlargement of the spleen and tenderness over the 
long bones and sternum and perhaps enlargement of 
the lymph glands, and the lymphatic type, in which 
the enlargement of the lymph glands is of greatest 
significance, the spleen increase being of secondary 
importance. 

In the splenic type there is a large increase in 
myelocytes. The white corpuscles as a whole are 
increased, usually exceeding 150,000 per cubic milli- 
meter. The polynuclear forms are greatly increased 
and eosinophils and mast cells appear in much greater 
number than normally. 

In the lymphatic type, the number of lymphocytes is 
greatly increased, forming 80 to 90 per cent, of the 
whole. In some cases the total number of white cells 
is not increased, but the proportion of lymphocytes is 
much greater than normally. 

The onset of the disease is insidious, among early 
symptoms being the splenic hypertrophy, enlargement 
of the superficial lymph glands, pallor, anemia and 
dyspnea. Local hemorrhages may appear externally 
or there may be hemorrhages into the internal organs. 
An irregular temperature with periods of pyrexia is 
not unusual. Gastro-intestinal upsets with nausea, 
vomiting and diarrhea also occur. In the acute forms 
of the disease death may occur in from four to six 
weeks. 



410 BENZOL IN LEUKEMIA 



TREATMENT 



Probably no problem which confronts the physician 
is more difficult than the treatment of leukemia. 
Seek and remove focal infection; then the main treat- 
ment is rest and nutrition, not unlike the treatment of 
pernicious anemia. In other words the treatment here, 
as in anemia, is an attempt to build up the resistance 
of the patient. As the finding of chief importance is 
the enormous increase in the number of white blood 
corpuscles, treatment has been directed toward coun- 
teracting this condition and lowering the count. 

ROENTGEN-RAY TREATMENT 

The roentgen rays seem to check the growth of the 
hyperplastic white-corpuscle-producing tissues, but 
overdosage may prove fatal, and too small doses may 
actually overstimulate these tissues. Although it is 
uncertain just how the roentgen rays act in these cases, 
there is no doubt that remissions occur following 
exposure of the spleen or of the long bones. The 
disease is not cured, however, and the patients usually 
relapse. The action of the rays should be controlled 
by blood examinations made frequently. Burning 
of the skin must be carefully avoided. Radio-active 
substances fail in about 20 per cent, of the cases, 
according to the literature to date. The action and 
effect seem to be about the same as with the roentgen 
rays; the lymphatic form seems tto be less ame- 
nable to the roentgen-ray reaction and recurrence is 
inevitable. 

BENZOL 

Benzol is commended by some and denounced by 
others. It certainly should not be given with disease 
of the liver or kidneys, or with, catarrhal intestinal 
trouble, and it should be suspended when the leuko- 
cytes have dropped to 20,000 or 25,000, before they 
have got down to normal figures. Von Koranyi (Berl. 
klin. Wchnschr. 12: 1357, 1912) first used benzene in 
the treatment of leukemia. All observers agree that 
the administration of benzene produces a marked rapid 
reduction of leukocytes, but the permanency of the 
improvement is not yet established. The benzol used 




HODGKIN'S DISEASE 411 

enterically is best given with an equal volume of olive 
oil, in hard gelatin capsules which may be first coated 
with keratin or salol before administration. It seems 
advisable to begin with a dosage of 5 minims of 
benzene three or four times a day and increase over 
a period of four weeks up to 30 minims three times 
a day. 

Bourges (Bull, de la Soc. Med. des Hop, Paris, 42: 
1149, Dec. 6, 1918) found marked improvement in 
leukemia following the administration of 50 drops of 
benzol in milk three times a day, although the improve- 
ment was not permanent and the patient subsequently 
relapsed, after which the benzol was unable to produce 
any effect. The treatment should be begun early in the 
disease, as it is in the early, almost latent stage that 
benzol may have its best effect. 

Every ten days suspension of the treatment should 
occur so that the effects on the gastrointestinal tract 
may not be too marked. In the interval raying of the 
spleen or exposure of the spleen to radium may be 
tried. 

The coincident administration of drugs to overcome 
anemia and the gastro-intestinal upsets is, of course, 
advisable. 

Haughwout has recommended the use of benzyl 
benzoate. He makes no claim as to its therapeutic 
efficiency, but it has the merit of not deranging the 
alimentary tract and the kidneys. The initial dose is 
10 drops of a 20 per cent, alcoholic solution in water 
three times a day after meals. In a considerable num- 
ber of cases in which it has been tried the observers 
report general improvement in the symptoms. 

Surgically, removal of the spleen has been performed 
in these cases but with no definite promise of perma- 
nent cure. 

HODGKIN'S DISEASE 

The etiology of Hodgkin's disease is still doubtful. 
Once established, the disease may show remissions, but 
patients seldom recover and the physician is encour- 
aged if his patient shows latency over four or five 
years. In 1913 a number of observers were 
able to grow a pleomorphic diphtheroid organism, 
gram-positive, in pure culture from the tissues in 



412 TREATMENT OF HODGKIN'S DISEASE 

this disease, and its introduction into animals resulted 
in establishing a series of similar changes in these 
animals. The disease manifests itself by a lymphan- 
gitis, perilymphangitis, and lymphadenitis. In the 
early stages the process is local, though an increase 
in the lymphoid cells of the blood is apparent. In the 
later stages there are definite toxemia and anemia, and 
still later with wide dissemination, edema, dysphagia, 
etc. In a complete study of this subject Bunting and 
Yates (Jour. A. M. A., June, 1915) state that in the 
acute forms death may result in two to four months 
and in the more chronic forms life may be prolonged 
up to five years. One of the most characteristic fea- 
tures of the disease is the alternate periods of exacer- 
bation and remission in the intensity of the process. 
During such remissions the treatment then in use is 
often given credit for the improvement. 

BLOOD PICTURE 

There are two types, an early and a late, showing 
a constant increase in the number of platelets with 
abnormally large forms and either a relative or abso- 
lute increase in the so-called transitional cells. In 
the early type the leukocytes are usually less than ten 
thousand; the lymphocytes are slightly above normal. 
In the late type there is a leukocytosis which may reach 
one hundred thousand, and the lymphocytes are 
reduced as low as 5 per cent. The transitional type 
may be above 8 per cent., the neutrophils being rela- 
tively increased to a percentage of from 75 to 92. 

TREATMENT 

Where the involvement is primarily cervical, even 
if the tonsils appear normal, a complete pericapsular 
tonsillectomy is indicated. If the primary glandular 
involvement is extra cervical, the source of infection 
must be found and the suspicious lesions appropriately 
treated. Excision of the cervical glands should be 
done as early as possible. Axillary dissections should 
be as extensive and as thorough as the cervical. It 
may be necessary to extirpate inguinal glands, as they 
are sometimes primarily involved. In later stages of 
the disease it is often difficult to .make these severe 



PURPURA HEMORRHAGICA 413 

dissections. Burnam on the basis of observations in 
more than 100 cases advises against extensive oper- 
ative removals. He uses radium treatment supported 
by rest in bed, forced feeding and iron. When radium 
is not available the roentgen ray is employed. The 
treatment varies with the individual patient and is 
guided by examinations of the blood at regular inter- 
vals. 

Roetgen-ray treatment has often given rise to 
marked improvement, although recurrences seem 
inevitable. 

Tonics may be indicated, iron and arsenic being 
preferable. Benzene has been given, but with no 
definite promise of success. 

The patients should be examined at regular inter- 
vals to determine how they progress, and the prognosis 
should always be extremely guarded. 

PURPURA HEMORRHAGICA 

This name should not be applied to every disease 
in which there are hemorrhagic spots (purpura) in 
the skin, but to the condition formerly known as the 
morbus maculosus of Werlhof. It is usually charac- 
terized by severe small hemorrhages not only into the 
skin but also into and from the mucous membranes. 
There may also be constitutional disturbances such as 
fever, nausea and vomiting. There may be hemor- 
rhages from the nose, the rectum or from the stomach. 
The etiology of the condition is unknown. It has been 
attributed to changes in the blood or to changes in 
the walls of the blood vessels. The common belief 
is that the disease is caused by some alteration in the 
constituents of the blood. Duke has shown that in 
all of the cases of purpura hemorrhagica studied there 
was a marked diminution in the number of blood plate- 
lets. Whereas in normal cases the count is between 
200,000 and 400,000, in purpura hemorrhagica it was 
below 10,000, many of the counts being below 1,000. 
He found the coagulation time normal and the clot at 
any bleeding point firm and without retraction. In 
this way a differential diagnosis could be made from 
hemophilia, in which the blood platelets are normal 
in number but the coagulation time is delayed. 



414 HEMOPHILIA 



TREATMENT 



As a result of the various etiologic studies of this 
condition the treatment has generally been aimed 
toward overcoming the deficiency in blood platelets. 
Thus blood transfusion is indicated with blood from 
a donor who shows a high count of blood platelets 
and whose blood is otherwise compatible. In addition 
to direct transfusion of blood, normal or citrated, 
human serum, etc., many have used intramuscular 
injections of whole blood in doses of twenty cubic 
centimeters. Some physicians have injected horse 
serum and achieved successful results. Frank gave 
arsenic in conjunction with local or intravenous injec- 
tion of an extract of blood platelets. Halpern and 
others have reported the successful use of subcutane- 
ous injections of various preparations of the blood 
platelets which are described in New and Nonofficial 
Remedies. Coagulen, for instance, is a yellow powder, 
readily soluble in water and not destroyed by steriliz- 
ing, prepared from the blood platelets of animals. 
When ready for use one grain is dissolved in 10 c.c. 
of distilled water. 

Aside from the use of fresh air, good food, rest, and 
the various tonics described under the treatment of 
anemia, the use of calcium lactate to increase the 
coagulability of the blood has many advocates. This 
may be given in doses of gm. 0.15 or 2 grains every 
two hours or gm. 0.5 or 7*4 grains every four hours 
or three times a day. 

HEMOPHILIA (BLEEDERS) 

Hemophilia is a condition, usually hereditary, char- 
acterized by a decrease in the coagulation time of the 
blood and sometimes resulting in death from hemor- 
rhage. The hemorrhage may be spontaneous, or it may 
be initiated by a cut, bruise or blow. The bleeding is 
not limited to any one part of the body. 

Hemophiliacs, commonly known as "bleeders," are 
of the male sex. Female "bleeders" have been reported 
occasionally, but not enough evidence is furnished to 
show that these are true hemophiliacs. The disease is 
transmitted through the female members of the fam- 
ilies to their male offspring. Such cases can be traced 



SYMPTOMS OF HEMOPHILIA 415 

through generations of families, several male members, 
but not all necessarily, of one generation being affected. 
Often the hemophilic tendency will make its appear- 
ance early in infancy, occurring at birth when the 
umbilical cord is severed. 

Various theories have been advanced as to the eti- 
ology of this condition. These can be divided into two 
groups: (1) deficiency in one or more of the blood 
elements, and (2) deficiency in the elements of the 
cells of the blood vessel walls. In the first group the 
hemorrhage has been attributed to lack of calcium, 
deficiency of prothrombin, or to an excess of anti- 
thrombin. Weil has even claimed the presence of 
anticoagulants in the blood. On the other hand, it has 
been asserted that there is abnormal fragility of the 
blood vessel or that there is lacking in the cells of the 
wall a fibrin-forming substance — thrombokinase. 

Certain factors relating to the blood in hemophilia 
have been definitely proved. It has been repeatedly 
shown that the coagulation time of the blood is pro- 
longed. Normally blood will coagulate in from ten 
to twenty minutes; with the same methods for deter- 
mining coagulation time of the blood in hemophiliacs, 
it has been shown that the coagulation time may be 
prolonged for as long as five hours. Hess states that 
the coagulation time should be taken at different 
periods, since occasionally it may approach normal. It 
is probable that on the occasions when it approaches 
nomal there is admixture of juices containing throm- 
bokinase from tissue at the site of puncture. Duke 
and others have shown that the blood platelet count in 
hemophilia does not vary from the normal, whereas in 
, purpura hemorrhagica it is lower than normal. In 
exceptional cases, such as one mentioned by Hess, the 
calcium content has been found unchanged. Howell 
found a deficiency in prothrombin, the antithrombin 
being normal or only slightly increased. 

SYMPTOMS 

A hemophiliac may be unrecognized until hemor- 
rhage occurs from a simple cause or spontaneously. 
Profuse epistaxis is frequent, or severe hemorrhage 
may follow tooth extraction, or there may be bleeding 



416 TREATMENT OF HEMOPHILIA 

into the stomach or intestines. The hemorrhage ma] 
be subcutaneous, following blows, and resulting in the 
formation of hematomas. A well known symptom of 
hemophilia is effusion into the joints. The larger 
joints are most often affected, particularly the elbow, 
knee or ankle joint. This hemarthrosis may first man- 
ifest itself by pain in the joint, soon followed by swell- 
ing. Occasionally fever is associated with it. The 
true nature of the condition is often not diagnosed, a 
common diagnosis being articular rheumatism or 
tuberculous arthritis. Operations based on incorrect 
diagnoses have resulted fatally. If the joints are not 
opened, but are treated gently by massage or heat, the 
effusion of blood disappears, sometimes within a few 
days, or sometimes only after weeks or months. 
Recurrences may follow, but the tendency for this 
grows less as the patient becomes older. Following 
one absorption of blood there may be a partial anky- 
losis. 

TREATMENT 

The treatment of hemophilia up to within a recent 
period has been as varied as the theories of its cause. 
Recently it has become more uniform because of suc- 
cessful experiences covering a large number of cases. 
Treatment may be general and local. It depends to 
a great degree on the location of the hemorrhage. If 
there has been considerable loss of blood, the patient 
should be supplied with sufficient fluids to help make 
up this loss. Milk is recommended, both on account 
of its calcium content and because of its nutritive 
value. If marked anemia is present, iron in con- 
venient form should be given. This may be adminis- 
tered by the saccharated oxid, in 3-grain tablet, 
crushed with the teeth before swallowing, one tablet 
two or three times a day, after meals ; as the reduced 
iron in 0.10 gm. dose, in capsule, two or three times a 
day, after meals ; the Blaud pill, 3 grains, two or three 
times a day after meals, or the tincture of the chlorid 
of iron in 5-drop doses, in fresh lemonade or orange- 
ade, three times a day, after meals. As has frequently 
been stated, there is no advantage in an organic iron 
over an inorganic iron, and there is no necessity of 
giving large doses of iron in simple anemia. 



SERUM IN HEMOPHILIA 417 

For directly shortening the coagulation time of the 
blood two methods have been tried. The first con- 
sists of the administration of empiric remedies sup- 
posed to supply one of the missing factors necessary 
for coagulation. Calcium in some form frequently 
is of benefit in these cases. It may be administered 
as simple lime water in tablespoonful doses, three or 
four times a day, given in water or milk ; or as calcium 
lactate in dose of 0.3 gm. (5 grains) given in some 
solution three or four times a day. Calcium chlorid 
is perhaps most frequently used, but it is more irritant 
and of no greater efficiency than other forms of 
calcium. 

SERUMS AND BLOOD 

The best results obtained have followed the use of 
serums. Various kinds have been administered, among 
which are rabbit, horse and normal human serum. 
The serum has been used in different forms freshly 
obtained from the blood in the form of plain horse 
serum or weak preparations of diphtheritic antitoxin 
when other serum is not available; also solutions of 
the dried serum. Of late controversy concerning 
serum therapy has been confined mainly to the kind of 
serum producing the best results. All are agreed as 
to the value of serum in hemophilia. 

Serum may be administered intravenously, sub- 
cutaneously, or applied locally to the bleeding point, 
if it can be reached. When given intravenously or 
subcutaneously, proper aseptic precautions should be 
taken. For intravenous injection, from 10 to 20 c.c. 
can be given every day until the bleeding stops, 
whereas for subcutaneous injection this dose should 
be doubled. The intravenous injection has great 
advantage over other methods, since by mixing inti- 
mately with blood it supplies more rapidly the absent 
elements necessary to increase the coagulability of the 
blood. When given subcutaneously, the serum must 
first be absorbed into the blood stream from the tis- 
sues, and before this can occur it will probably undergo 
a certain amount of change from action by the tissue 
cells. 

Normal human serum, if this can be obtained, is 
without doubt the best to use, since it contains no for- 
eign proteins. 



418 TISSUE EXTRACTS IN HEMOPHILIA 

It has been found that following the administration 
of rabbit, or more particularly, horse serum there 
occasionally follows definite symptoms to which have 
been given the name "serum sickness." This con- 
sists of a rise in temperature and the formation of an 
urticarial rash, the rash often being surrounded by an 
area of edema. The urticarial rash often fades into 
a scarlatiniform rash that lasts for several days. 

Horse serum or diphtheria antitoxin is a most con- 
venient remedy, as it is easily obtainable. The possi- 
bility of anaphylactic shock must be borne in mind and 
guarded against by first testing the patient with a small 
dose, as 1 c.c. given subcutaneously. It should be 
known that the patient does not suffer from asthma or 
hay fever from horse emanations. 

Emile-Weil (Bull. Acad, de med. 82:374, 1919) 
found most marked improvement in his cases following 
the injection of serum. In one case serum failed until 
the patient showed a state of anaphylaxis through the 
development of urticaria and other signs of serum dis- 
ease. This was followed by an immediate cure of the 
disease. Although it is dangerous to produce such a 
state it is possible to confer passive anaphylaxis on the 
patient by injecting small doses of serum from human 
beings or animals already in an anaphylactic state. The 
serum was prepared by injecting rabbits with small 
doses of horse serum and its use in sixteen cases is 
reported as satisfactory. 

Whole blood injections should not be given into the 
veins unless preliminary agglutination and hemolysis 
tests have been carried out just as for transfusion in 
other conditions. 

Good results have been reported from the use of 
tissue extracts applied locally to the bleeding point. 
These tissue extracts have been thyroid, ovary, liver, 
pancreas, kidney and spleen. The thyroid extract has 
been used most frequently. No good reason has been 
offered for the hemostatic properties of tissue extracts. 
Not infrequently profuse hemorrhages have been 
stopped by the administration of thyroid. While thy- 
roid extract increases a liability to hemorrhage in most 
individuals, and may even cause menstruation or 
increased menstrual flow in some instances, in hemo- 



TRANSFUSION IN HEMOPHILIA 419 

philiacs it has at times been successful in stopping 
bleeding when other treatments have failed. Also, 
occasionally in profuse bleeding occurring at the time 
of the menopause, thyroid substance given in large 
doses, as much as 4 grains of the dessicated thyroid 
three or four times a day for a few days and then the 
dose reduced, has stopped bleeding when all other 
medication has failed. 

As a last resort, transfusion itself may be tried. The 
usual precautions should be taken, the blood of both 
patient and donor being tested for hemolytic and agglu- 
tinative properties. A Wassermann test of the donor's 
blood should also be made. Ottenberg and Libman 
state that "every individual known to have hemophilia 
ought to have at his command several persons whose 
blood, by previous tests, is known to be compatible with 
his and who are willing, when called on, to give blood 
for transfusion." If these blood tests have been made 
a long time before, the character of the blood may have 
changed ; therefore such tests should not be relied on, 
but fresh tests should be made. They also state that 
in transfusions some blood element is supplied that has 
been lacking, and on that account the cure is not always 
permanent as the supply is only temporary. They 
report a series of five hemophiliacs who were trans- 
fused, and in every case the hemorrhage stopped after 
transfusion. 

Inasmuch as there is a high mortality in hemophilia 
unless the hemorrhage is promptly and completely 
checked, advantage should be taken of every available 
means to obtain serum or to make arrangement for a 
transfusion. If there is no source from which fresh 
serum can be obtained, and if for any reason transfu- 
sion cannot be done, horse serum or antidiphtheritic 
serum, which can always be procured, should be 
injected. 

After a hemorrhage the patient is necessarily con- 
siderably weakened and may be anemic. He should 
then receive rest and supportive treatment as described 
in other blood diseases. 



DISTURBANCES OF THE THYROID 



HYPERTHYROIDISM 

The etiology of hyperthyroidism is not yet deter- 
mined. There are probably many causes, but among 
the most frequent causes is focal infection, in the 
mouth or tonsils. Many cases seem to recover 
promptly after the removal of the infected material. 

SYMPTOMS 

Disturbance from perverted thyroid functioning 
develops very insidiously as a rule. At first there are 
symptoms of a general nervous disturbance. Other 
symptoms are gastrointestinal upsets; bruits, tachy- 
cardia, abnormal sweating, tremors, flashes of heat, 
digestive disturbances, signs of excessive mental irrita- 
tion, and in women, menstrual disturbances. 

LABORATORY TESTS FOR HYPERTHYROIDISM 

According to Goetsch, in states of hyperthyroidism 
there is a hypersensitiveness to epinephrin. In a posi- 
tive reaction a subcutaneous dose of epinephrin is char- 
acterized by an early rise in blood pressure and pulse 
varying from 10 to 50 and normally proportional to 
the degree of toxicity present. There is also moderate 
exaggeration of the symptoms such as asthenia, tremor, 
throbbing, vasomotor changes, apprehension and ner- 
vousness. Experience shows that the test is a measure 
of the sensitization of the sympathetic or vegetative 
nervous system. Its value as a diagnostic test in hyper- 
thyroidism is increased when blood and urinary sugar 
estimations are recorded with pulse rate blood pressure. 
Lueders (Arch. Inter. Med., 24:432, 1919) finds it 
cannot be relied on to any great extent, but there is a 
considerable difference of opinion. 

Tests of sugar tolerance, nitrogen loss and acidosis 
have been made by Lueders in cases of hyperthy- 
roidism. He believes the latter two are suggestive as 
aids in the diagnosis. Since the nitrogen metabolism 
is increased in exophthalmic goiter there is nitrogen loss 



TREATMENT OF HYPERTHYROIDISM 421 

by way of the kidneys and bowel. The severer symp- 
toms and the more striking signs of acute toxic goiter 
are suggestive of acid intoxication with depletion of the 
blood carbonates. The tests described under diabetes 
may therefore be applied and may reveal interesting 
information in cases of hyperthyroidism. 

The best recognized test for hyperthyroidism is the 
basal metabolism determination as developed by Mag- 
nus-Levy, Ruber and many others. For this purpose 
the special Benedict apparatus is required. 

Means and Aub (Arch. Inter. Med. 24:404, 1919) 
found that the metabolism showed a definite reduction 
below that of normal individuals of the same age and 
sex in cases of hypothyroidism and markedly increased 
metabolism in hyperthyroidism. 

TREATMENT 

The treatment of hyperthyroidism is based on two 
main factors : alleviation of symptoms and removal of 
the foci of infection which may be responsible. These 
patients should have rest in bed, freedom from all 
excitement, and a modified diet for a few days before 
and after subjecting the patient even to such minor 
operations as tonsillectomy or extraction of teeth. 

Rest. — In the treatment of hyperthyroidism some 
of the most important general factors are freedom 
from mental and physical fatigue, and from all excite- 
ment. Rest in bed is the best method of obtaining this, 
but cessation of work, and rest at home are in many 
cases sufficient. Exercise should be moderate, espe- 
cially in those cases in which there is more or less 
tachycardia; otherwise, permanent injury to the heart 
may result. The digitalis preparations have practically 
no effect on this type of tachycardia; indeed, digitalis 
poisoning may result without any slowing of the pulse. 

Excitability. — For the general nervous excitability, 
rest in bed is again the best treatment. Bromids may 
be used, but are apt to increase the general debility of 
the patient. Opiates are contraindicated even though 
they always reduce thyroid secretion. Calcium medica- 
tion is sometimes beneficial. 

Diet. — The diet in mild cases should consist of sim- 
ple foods the variety of which need not be limited 



422 ROENTGEN RAY IN HYPERTHYROIDISM 

except that it is better to eat but little meat. Tea and 
coffee should of course be omitted. Caffein, strychnin 
and other general stimulants are contraindicated, as 
they tend to aggravate the nervous symptoms. In the 
more severe cases a meat free diet is advisable. Dubois 
found by calorimetric studies that the metabolism of 
these patients averages one and a half times more than 
normal. His studies should make it clear that these 
patients require rest to diminish the metabolism and 
large amounts of carbohydrate foods to prevent loss 
of body fat, and protein. 

Infective Foci. — As already stated, an important 
factor in the treatment of hyperthyroidism is the 
removal of the foci of infection. With this in mind, 
teeth, tonsils, sinuses, gallbladder, appendix, genital 
organs, etc., should all be carefully studied and then 
treated as necessary to clear up any infection. The 
importance of completely clearing up foci of infection 
is illustrated by the way in which symptoms persist 
even after partial thyroidectomy when foci of infec- 
tion remain unattended to. 

Specific Preparations. — Iodin, iodids, thyroid extract 
and the crystalline active principles of Kendall's group, 
described later, generally aggravate the symptoms and 
so are contraindicated. The constituents of Kendall's 
Group B would tie beneficial in those cases of exoph- 
thalmic goiter in which there are some of the skin 
changes of hypothyroidism. There are a number of 
preparations on the market that are derived from 
thyroidectomized animals which seem to be beneficial 
in some cases. The extract of thymus, epinephrin, ana 
pituitary extract sometimes seem to alleviate the symp- 
toms. 

Roentgen Ray. — The roentgen ray has been used 
with excellent results. It should, however, not be 
used indiscriminately as, if not administered by a 
skilled radiotherapist, serious injury may result. The 
effect of radium on goiter is quite similar to that of 
the roentgen ray. Means and Aub found that exposure 
to roentgen ray and rest in bed benefited many of their 
patients. Coincident with the treatment occurred a 
reduction in metabolism to 20 per cent, of its former 
level. Holmes and Merrill (Jour. A. M. A. 73: 1693, 



STRUMA OF THE THYROID 423 

1919) found that exposure to the roentgen ray 
decreased the activity of the thyroid gland and 
destroyed glandular structure. It produced relief of 
the symptoms in thyrotoxicosis. Its effects are esti- 
mated through determinations of the basal metabolism. 
They recommend that the roentgen ray accompanied 
by rest be tried in all cases of thyrotoxicosis. Treat- 
ment should be continued for a sufficient length of time 
to destroy at least the thymus before trying surgery. 

Surgery. — Surgery is at present a much used thera- 
peutic agent in the treatment of hyperthyroidism. 
Ligation of the superior thyroid arteries and partial 
thyroidectomy are both of great value in alleviating 
symptoms. It is, however, generally recognized that 
relatively few cases of exophthalmic goiter are actually 
permanently cured by surgery. Some symptoms per- 
sist or recur, if only when the patient is fatigued or 
excited. Injections of boiling water, quinin and urea 
hydrochlorid, etc., have been recommended for destroy- 
ing part of the gland. 

Thymus. — Many cases of exophthalmic goiter are 
complicated by an enlargement of the thymus. The 
adrenals often are insufficient in this disease and epi- 
nephrin may be indicated to prepare the patient for 
operative treatment. Thymic hyperplasia greatly 
increases the risk in surgical treatment of the thyroid. 

CONCLUSION 

If the weight and strength keep running down and 
the heart functioning growing worse, an operation 
should be recommended without delay, but otherwise 
not until after a thorough course of medical mea- 
sures. For operative treatment, the objective symp- 
toms form the criterion. After operative treatment 
the patient requires medical oversight as much as 
after an operation for gastric ulcer. 

SIMPLE STRUMA OF THE THYROID 

It is possible that the simple strumous hyperplasias 
of the thyroid are due to an infection, but this has not 
been proved. The only cause for treating the colloid 
goiter which is causing no symptoms is to reduce the 
size of the gland, as a goiter is unsightly. Some colloid 



424 HYPOTHYROIDISM 

goiters become large enough to interfere with degluti- 
tion and respiration: in such cases, of course, surgery 
is indicated. Iodin, iodids and thyroid extract are 
sometimes effective in reducing the size of the gland. 
E. C. Kendall's active principle of the thyroid may 
prove of value in some of these cases. 

Removal of foci of infection may prove of value in 
the treatment of these goiters. If they are infectious, 
removal of the foci should at least stop further increase 
in size and also should make a change to the exoph- 
thalmic type most unlikely. So, removal of foci of 
infection is indicated even in the simple strumous 
goiters. 

For the simple goiters of puberty little or no 
treatment is needed, as they usually disappear spon- 
taneously. 

HYPOTHYROIDISM (HYPOSECRETION) 

Hyposecretion of the thyroid gland, the cause of 
which is not yet known, may be present in the following 
conditions, either as a cause or as an accompanying 
complication : 

Chlorosis Melancholia 

Amenorrhea Slow growth in children 

Obesity Cretinism 

Goiter Adiposis dolorosa 

Eczema Lipomatosis 

Hysteria (depressant forms) Myxedema- 

Vomiting of pregnancy Senility 

Epilepsy 

Typical symptoms of hypothyroidea are best recog- 
nized and studied in the adult female. If there is 
absolute absence of secretion, myxedema develops. A 
normally diminishing secretion, such as occurs after 
45 or 50 years of age, is shown by symptoms, the most 
evident being the addition of flesh, especially deposits 
of fat, a slowly increasing blood pressure, and a 
gradual development of connective tissue in various 
parts of the body. If this secretion diminishes nor- 
mally as age advances into old age, the skin begins to 
lose its nutrition and dries and wrinkles, with a ten- 
dency to the occurrence of eczemas. 



USES OF THYROID EXTRACT 425 

PRINCIPAL USES OF THYROID 

The absence of menstruation, after puberty, without 
pregnancy or acute or chronic disease, may point to a 
diminution of the thyroid and ovarian secretions. If 
the patient is anemic, iron and ovarian extract should 
be the treatment. If the patient is not very anemic and 
tends to put on weight, thyroid extract may be used in 
the treatment. The dose of thyroid should be small, 
not more than 3 grains, often less, of the dried extract 
once a day. 

There has never been a satisfactory explanation of 
the condition of chlorosis. For some reason these 
patients do not metabolize the iron of their food. 
Large doses of iron always cure these patients. If 
these girls begin to menstruate normally the disease 
disappears, and thyroid extract acts as an efficient 
emmenagogue. 

Infantile obesity is modified by small doses of thy- 
roid, and if recognized early the condition may be 
inhibited. The disturbance in metabolism that is most 
frequently improved by thyroid is obesity. Thyroid 
will probably cause loss of weight in every instance 
provided a sufficient amount is given, but at the same 
time there is a great nitrogenous loss, and there is 
always the danger of causing disturbances due to an 
increased amount of thyroid in the blood, some of 
which may be serious. It can cause faintness and loss 
of strength, and a debility which may not be recovered 
from in a considerable length of time. If weight is 
being added, especially in women after 45, small doses 
of thyroid may prevent it. If the fat is already pres- 
ent, it may take considerable dosage to reduce it. The 
large doses which were once used for this purpose are 
not justifiable, and a patient under thyroid treatment 
for obesity should be very carefully watched, and the 
administration should cease as soon as any unpleasant 
symptoms appear. When weight is put on in younger 
life, especially in women, thyroid, and often pitui- 
tary extracts, is the most efficient treatment, and 
the dose required is generally not large. The 
value of combining such treatment with a diet free 
from sugar and with -a diminished amount of carbo- 
hydrates, and with physical exercise, should not be 



426 SIGNS OF HYPOSECRETION 

overlooked. The dose of thyroid should be 0.2 gm. 
(3 grains), at first three times a day for a week, then 
twice a day for another week, and after this once a day 
will probably be sufficient. To be sure that the thyroid 
is active, 0.25 gm. (4 grains) of sodium iodid should 
be adminstered once during each twenty-four hours. 
The patient may not begin to lose weight for at least 
two weeks, and after that some weight should be lost 
every week, and patients may lose weight even after 
the treatment has been stopped. The loss of two or 
three pounds a week should be considered sufficient 
and satisfactory. If the excessive weight is hereditary, 
or has persisted for years, the fat will again return on 
cessation of the treatment, and in these patients great 
loss of weight will not be caused by the treatment 
without the necessity for more thyroid being admin- 
istered than is safe. Patients who are receiving thy- 
roid should be watched carefully for symptoms of 
excessive thyroid administration. It is well to begin 
with a small dose and increase gradually. It has been 
suggested that the recumbent pulse be not permitted 
to go above ninety. When it does the treatment should 
be discontinued. 

SIGNS OF HYPOSECRETION 

If undesirable fat begins to be deposited before 
the age of 40, unless there is a marked family ten- 
dency to such excessive weight, the thyroid is prob- 
ably undersecreting. If such deposits of fat occur on 
the hips, over and under the clavicles, on the upper 
arms, around the breasts in women, with a feeling of 
oppression, dyspnea on exertion, and especially if 
menstruation has ceased, the diagnosis is absolute that 
the thyroid is secreting insufficiently. If this condition 
just described further develops, adiposis dolorosa is 
in evidence, the only difference being that of degree 
and that the fatty parts are painful. The thyroid is 
always found to contain a large amount of connective 
tissue and to be subsecreting in this disease. In the 
rare instances of general and localized lipomatosis the 
thyroid is probably not perfectly active, although other 
signs of its inactivity may not be present. Thyroid 



THYROID IN PREGNANCY 427 

will always improve the condition of the skin even if 
it does not inhibit the advance of the disease. 

Many eczemas of early childhood are often incorri- 
gible until minute doses of thyroid are administered. 
These are especially the type that occur around the 
orifices of the body, and when fissures or cracks 
in the skin occur. The troublesome eczemas of old 
age often will not heal with local treatment until 
small doses of thyroid are added to that treatment. 
Sometimes the results obtained by such treatment of 
these patients is most satisfactory. 

Hysteria of the melancholic, depressant type, where 
there is apathy, unwillingness to talk, and general 
depression, may be improved and cured by the admin- 
istration of small doses of thyroid. The border-line 
between .this kind of hysteria and beginning melan- 
cholia is hard to determine, but the cerebral stimula- 
tion caused by thyroid will sometimes prevent the 
development of insanity. Whether actual melancholic 
insanity is benefited by thyroid is doubtful, but it cer- 
tainly is a treatment sufficiently logical to be tried in 
every case. 

VOMITING OF PREGNANCY 

There have been many suppositions as to the cause 
of the persistent vomiting of pregnancy. Whether it is 
purely reflex or whether there is a metabolic poisoning 
of the system of which vomiting is a consequence, it 
seems certain that any method that allows the mother 
to metabolize her food better, and eliminate the nitro- 
gen excretory products properly, will be of benefit to 
her. Whether there is often or occasionally a subse- 
cretion of the thyroid during the early months of 
pregnancy when vomiting is so likely to be in evidence 
is not known, but many instances have been reported 
in which the administration of small doses of thyroid 
has improved such a serious condition. It is certain 
that the thyroid will increase the nitrogenous output 
in the urine. It is also certain that the thyroid should 
hypersecrete during pregnancy. If it does not do so 
it is acting abnormally, and the vomiting of preg- 
nancy may be an indicator of such a defect. 

It is certainly advisable, when a woman has given 
birth to one or more children who have shown sub- 



428 MYXEDEMA 

thyroid activity, to administer to her thyroid gland 
substance during her next pregnancy. Such treatment 
is logical, and has been successful in producing healthy 
children. If it is inadvisable to give small doses of thy- 
roid to a pregnant woman or if its results are unsatis- 
factory, small doses of iodid may be substituted when 
it is decided that the patient's own thyroid is not 
secreting properly. 

Epileptic attacks are frequently associated with 
arrests and deviations of body growth such as occurs 
in disorders of the internal secretions. In such cases 
thyroid in doses of from 3 to 5 grains daily (depending 
on the symptoms of the physiologic action of the thy- 
roid) may be given in the intervals between attacks. 
Epilepsy developing at the menopause is often bene- 
fited by thyroid treatment. 

MYXEDEMA 

More or less complete insufficiency of the thyroid 
in adults causes myxedema. This is a rare disease in 
men, and occurs in more than 80 per cent, of all cases 
in women, and mostly in those who have borne chil- 
dren. It would seem from such statistical facts, that 
the gland is inclined to excessive atrophy because it 
has previously been overworked, in women, from the 
periodicity of its increased secretion on account of 
menstruation, and from its overwork during preg- 
nancy. The treatment is thyroid ; all of the symptoms 
disappearing. The dose should not be large, but if for 
any reason the treatment is rapidly pushed, the patient 
should be in bed lest sudden heart failure occur from 
the large doses of thyroid. As soon as the patient 
improves, the dose should be reduced; a dose of 3 
grains of the dried gland substance a day is sufficient, 
and even this may subsequently be given but every 
other day, or even less frequently. Sometimes the 
thyroid gland of such a patient may be stimulated or 
may recuperate, or perhaps a supernumerary thyroid 
may develop so that active thyroid medication is needed 
only intermittently. 

In operative myxedema in which the thyroid gland 
has been removed totally, or so much has been removed 



CRETINISM 429 

that the secretion of the remaining portion is insuffi- 
cient, or in some instances of true myxedema, in which 
the patient cannot live without continued thyroid treat- 
ment, transplantation or implantation ol* thyroid gland 
tissue into various organs of the body has been tried, 
sometimes with success. The same implantation has 
been tried in cretins, and there are records of success. 
The younger the patient, the more successful, perhaps, 
is the treatment, but the whole subject of such trans- 
plantation is as yet purely experimental. 

CRETINISM 

In cretinous children the thyroid is either absent, or, 
if present, contains a small amount of colloid material 
or is cystic, and there is almost entire absence of thy- 
roid secretion. The curative action of thyroid in cre- 
tinism is a demonstrated fact, and the sooner the diag- 
nosis of cretinism is made, the greater the amount of 
success which will attend the use of thyroid. Unfor- 
tunately, the diagnosis of cretinism can rarely be made 
until the child is from 6 months to a year old, and if 
there is not total absence of thyroid secretion an infan- 
tile myxedema cannot be determined until the child is 
2 or 3 years old. If a cretin or a patient with infan- 
tile myxedema is not treated until he is several years 
old the results of such treatment are much less satis- 
factory. The dose for an infant is not more than 
.065 gm. (1 grain) of the official thyroid powder, two 
or three times a day. If the cretin is older, the dose 
may be larger. Its unfavorable action is shown by 
increased cardiac rapidity and loss of appetite. Its 
favorable action is shown by a diminution of the myxe- 
dema ; in other words, the puffiness of the skin becomes 
less, and there is an actual loss of weight. The mental 
powers should increase, and the hair, nails, teeth and 
bones should grow normally. The thyroid feeding, 
as soon as improvement has positively taken place, 
should then be slightly diminished, and a smaller dose 
given daily for months and perhaps for. years. If 
unpleasant symptoms of thyroid action occur, the thy- 
roid should be stopped for a week and then be again 
begun at a smaller dose. 



430 ACTION OF THYROID EXTRACT 






UNCLASSIFIED USES OF THYROID 

Thyroid has been used with success in some instances 
of hemophilia and purpura hemorrhagica, as well as 
in the regular hemorrhages of the menopause. 

It has been used in chronic rheumatism as well as 
in arthritis deformans, and has many times been suc- 
cessful in gouty rheumatism, especially where the 
attacks showed a general disturbance of metabolism, 
such as at one time an asthmatic attack, at another an 
indigestion attack, and at another a typical gouty joint 
attack. Small doses given for a considerable time are 
often successful in this kind of metabolic disturbance. 

Sometimes thyroid acts as a diuretic, and it certainly 
is an antidote to nitrogenous poisoning in insufficient 
kidney action. Even uremic convulsions are some- 
times kept in abeyance by the administration of thy- 
roid. During a uremic attack the dose of thyroid 
should be large, as 10 grains of the dried extract three 
times a day. Such treatment sometimes apparently 
prevents convulsions and in some instances seems to 
aid in saving life. It has been used with success in 
puerperal eclampsia. 

Thyroid has been used in various skin diseases, 
sometimes with success. The indication seems to be 
to stimulate extra secretion of the skin. If there is 
an acute inflammation or hyperemia, thyroid would 
not be indicated. Conditions in which it has been suc- 
cessful are the dry chronic eczemas, sometimes in 
psoriasis, ichthyosis, and in some instances of sclero- 
derma. 

If not otherwise contraindicated, whenever there is 
excessive connective tissue development in any organ 
— in other words, a , sclerosis or cirrhosis — a small 
dose of thyroid daily is of benefit. The dose should be 
so small that it could not cause evident signs of its 
physiologic activity. In many of these instances small 
doses of iodid, given daily for long periods, may be of 
as much benefit. 

ACTION OF THYROID 

The following description of the action of the thy- 
roid extract is taken from "Useful Drugs": "Dried 
thyroid gland acts chiefly if not entirely through a 



ADMINISTRATION OF THYROID EXTRACT 431 

compound of iodin contained in it. When given in 
therapeutically active doses thyroid causes an increase 
of the nitrogen in the urine and a decrease in weight ; 
it usually increases the absorption of oxygen and the 
elimination of carbon dioxid. It is one of the very few 
drugs which can properly be called stimulants of 
metabolism. The loss of weight is due mainly to 
increased catabolism of adipose tissue, although there 
is an increased breaking down of protein unless the 
diet contains an abundance of protein. With larger or 
long continued doses there is a very rapid action of the 
heart, nervousness, tremors, headache, flushing of the 
surface, sweating and much more pronounced loss of 
weight." 

THE ADMINISTRATION OF THYROID 

Unless thyroid is administered in large doses to com- 
bat an intoxication or toxemia, as in puerperal eclamp- 
sia or uremia, a therapeutic dose should cause no evi- 
dent symptoms. In other words, if thyroid is to be 
administered continuously for its continued physio- 
logic effect it should give no more symptoms than does 
the normal thyroid secretion. Large doses may cause 
nausea, dizziness, and, if quickly absorbed, faintness. 
There is probably no direct acute poisoning from thy- 
roid, although large amounts have been known to 
cause convulsions and even death from shock, i. e. } 
by the toxic effect on the heart and the enormous vaso- 
dilator effect, as has been seen in operations for 
Graves' disease when the thyroid has been too much 
manipulated and a large amount of its secretion has 
been absorbed. 

The treatment of acute thyroid intoxication would 
be the hypodermatic or intravenous use of epinephrin 
or post pituitary extract, the administration of atropin 
and strychnin. Possibly good treatment would be 
bleeding from one arm while physiologic saline was 
transfused into the other arm. 

Contraindications. — Any symptom similar to those 
of exophthalmic goiter should ordinarily prohibit the 
use of thyroid. Also, if during the administration of 
thyroid excessive nervousness, sleeplessness, palpita- 
tion, and loss of weight occur, the administration 



432 KENDALL'S PREPARATION OF THYROID 

should be stopped. Ordinarily a poor condition of the 
circulation and a soft and weak pulse should prevent 
its use. Serious nervous and cerebral excitation 
should also ordinarily prevent its use. 

Official Preparation. — Thyroideum Siccum, desic- 
cated thyroid glands, is a yellow powder prepared from 
the thyroid glands of sheep. It has a disagreeable, 
meaty smell, and is partially soluble in water, This 
preparation, of course, contains the active principle of 
the thyroid gland, but its activity depends on the 
amount of the iodin content, and this is variable. It 
should contain about 0.2 per cent, of iodin. The dose 
varies from 0.03 gm. (% grain) to 1 gm. (15 grains), 
depending on the frequency and the object for which 
it is used. Thyroid may also be obtained in tablets 
which vary in size and strength. 

KENDALl/S PREPARATION 

Kendall has isolated two groups of active principles 
from the thyroid gland, the qualities and characteristics 
of which he summarizes as follows: 

1. By an alkaline alcoholic hydrolysis, the thyroid 
proteins are broken into many simpler constituents. 
These may be separated into two groups: the acid 
insoluble compounds are designated Group A; those 
acid soluble, Group B. 2. From Group A a pure 
crystalline compound, containing 60 per cent, of iodin, 
has been isolated. It appears to be di-iodo-di-hydroxy- 
indol. 3. Group B contains iodin in some unknown 
form of combination. It is a mixture containing 
amino-acid complexes and a low molecular weight. 
4. Administration of Group A produces in the dog and 
in the human being an increase in pulse rate and vigor, 
and increases in metabolism and nervous irritability. 
This physiologic activity is produced by the compound 
containing iodin in all stages of purity up to and includ- 
ing its crystalline form. 5. Given in excess, toxic 
symptoms are produced. The amount of the iodin 
compound required to produce toxic effects is exceed- 
ingly small. 6. In exophthalmic goiter two abnormal 
conditions exist: first, the secreting capacity of the 
gland is greatly increased and, second, the reservoir 



KENDALL'S PREPARATION OF THYROID 433 

capacity of the gland is greatly decreased. The iodin 
compound plays an important role in the production of 
the symptoms of exophthalmic goiter. 7. The con- 
stituents of Group B produce no toxic symptoms, but 
in cases of cretinism, myxedema and certain skin con- 
ditions, they exert physiologic activity. This active 
substance thyroxin can now be obtained through a 
manufacturer. 



DISEASES OF THE NERVOUS 
SYSTEM 



CHOREA 

Chorea — also known as chorea minor, Sydenham's 
disease, or St. Vitus' dance — manifests itself by mus- 
cular movements, mental irritability, sleeplessness, 
troublesome dreams and, perhaps, hallucinations. The 
most frequent age is from 5 to 15 years, and girls are 
affected three times as frequently as boys. Chorea 
is probably due to an infection and the frequency with 
which it follows inflammatory rheumatism, and 
chronic tonsillitis, as well as the common complica- 
tion of endocarditis, indicates an organism of the strep- 
tococcal series. In the search for its cause all foci of 
infection should be removed and all irritating factors 
such as constipation, worms, pruritus, headache, etc., 
controlled. 

TREATMENT 

As will ordinarily be noted, the child with chorea 
is anemic, restless, illy nourished — in fact, just the 
type to show a low resistance to infection. The pri- 
mary indication to be met, in view of this fact, and 
in view of the hyperirritability of the sensory-motor 
system is rest. It may be well at the outset to insist 
on absolute rest in bed for a few days or weeks. The 
child should be shielded from sources of irritation such 
as school work, other children, hard playing or even 
much walking. During the period of rest, massage" and 
passive motion may be instituted to prevent too great 
disuse of muscles and secondary atrophy. 

The diet should depend on the acuteness of the 
symptoms, whether fever be present and in relation to 
the patients appetite. A goodly quantity of a good 
milk may be freely given. Meat should be allowed in 
small quantities only, and such excitants as tea and 
coffee should be absolutely eradicated. 

Hydrotherapeutic and physical methods are 
undoubtedly of great value in chorea. The warm 



TREATMENT OF CHOREA 435 

bath is sedative and may be given daily or every other 
day. When accompanied by systematic massage or 
graded exercises it may achieve markedly good results. 

Patients with chorea should be thoroughly examined 
and local foci of infection, such as carious teeth 
or diseased tonsils, should be promptly eliminated. 
Furthermore such sources of continued irritation as 
phimosis, otitis media, worms, or adenoids should 
receive adequate attention. 

It has been suggested that some of these cases are 
stimulated by purely mental obsessions. An analysis 
of the mental processes with free questioning by a 
physician who has gained the patient's confidence may 
reveal such a hidden source, and an adequate explana- 
tion may be of invaluable aid in clearing up the 
symptoms. 

MEDICINAL TREATMENT 

Arsenic, as Fowler's solution, has long been a highly 
praised treatment for chorea and seems to succeed in 
some cases but most patients are probably better off 
without it. . 

The patient's bowels should be kept open and elim- 
ination encouraged by the use of laxatives such as 
castor oil and phenolphthalein. If there are joint 
pains, salicylates should be given. The heart should 
receive special attention, as it is frequently affected 
in chorea. 

If the twitching becomes violent or severe, it should 
be checked by the use of a hypnotic, and chloral is 
generally recommended for this purpose in a dosage 
sufficient to cause sleep — perhaps 5 grains every four 
hours for a child 6 years or upward. After the move- 
ments have ceased and the child is convalescent, iron 
should be given. 

A patient who has recovered from an acute chorea 
should be given an outdoor, quiet life for several 
months, and school, work should be absolutely pro- 
hibited. If the chorea has occurred at the time of 
puberty in girls, all excitement and the strain of 
school life should generally be forbidden until men- 
struation is regularly established. 



436 EPILEPSY 



AUTOSERUM TREATMENT 



,. 



A considerable amount of literature has accumulated 
favorable to autoserum treatment in this disease. 
About 50 ex. of blood are withdrawn from the patient's 
median basilic vein and centrifuged from thirty to 
forty minutes. The serum is pipetted of! under sterile 
precautions into a sterile test tube and put into an 
incubator where it is kept at proper temperature for 
injection. The serum is injected intraspinally and 
preferably in a hospital where proper care can be given 
to the patient. No solid food is given for six to eight 
hours following treatment. The symptoms subside and 
if they reappear further treatments may be adminis- 
tered at intervals of not less than one week. The aver- 
age amount of serum employed per injection is 17 c.c. 
and the average number of treatments required in each 
case, three. 

EPILEPSY 

The convulsions of epilepsy in a typical attack are 
sufficiently well known and require no renewed descrip- 
tion here. The etiology of epilepsy is unknown. There 
exists one class in whom the seizures are definitely 
related to certain traumatic lesions of the skull, brain 
or meninges, or to some actually demonstrable lesion 
in the brain. This type of case may often be relieved 
by operative methods. Another type of epilepsy seems 
definitely associated with intoxication. Of this theory 
there are many adherents. Another point of view of 
the origin of many cases of true epilepsy has been pre- 
sented by L. Pierce Clark after years of study of this 
disease. Clark believes that true epilepsy is a psychosis, 
and that each case should be studied with that idea in 
mind. 

Gowers and others have stated distinctly that often 
there may be a hereditary tendency to epilepsy. Still 
other observers are convinced that a state of alco- 
holism, lead poisoning, or other poisoning in either 
parent at the time of impregnation may be a cause of 
epilepsy. Turner has defined as idiopathic epilepsy 
"a chronic disease of the brain characterized by the 
recurrence of seizures in which interference with 
consciousness is an essential feature, associated either 
with convulsions or transient psychical phenomena, 



TREATMENT OF EPILEPSY 437 

occurring usually in persons with an hereditary neuro- 
pathic endowment and eventually leading to more or 
less permanent mental impairment and dementia/' In 
other words as, stated by Dercum, "One fact is prom- 
inent in all this, namely,, that epilepsy is not a specific 
entity but includes many symptom groups which differ 
widely as to their origin and pathology." Perhaps the 
most practical view to adopt is that stated by MacRob- 
erts (Jour. A. M. A. 74: 1000, 1920) after analysis of 
the whole subject : Epilepsy means a tendency to recur- 
rent convulsions; such a tendency implies a more or 
less generalized cortical instability; epilepsy is there- 
fore not properly due to any cause outside the brain. 

TREATMENT 

If the patient is in the midst of an attack, measures 
should be instituted to prevent him from being injured 
by the movements which accompany the convulsion. 
It is important that chewing of the tongue be pre- 
vented. Immediately after an attack the patient should 
be permitted to rest and recuperate before any active 
steps are taken to secure a history or to institute treat- 
ment. 

When one fit succeeds another in rapid order the 
patient may die, and the immediate administration of 
a large dose of chloral or bromids, or both, may be 
considered. • The following mixture has been recom- 
mended : 

Gm. or C.c. 

B Chlorali hydrati 5 3 iss 

Sodii bromidi 10 or 3 in 

Elixiris aromatici 50 fl5 ii 

Aquae q. s. ad 100 A3 iv 

M. Sig. As the physician directs. 

[Each teaspoonful of the above, i. e., 5 c.c, represents 0.50 
gram (7% grains) of bromid and 0.25 gram (4 grains) of 
chloral.] 

Chloroform inhalation will serve to stop and pre- 
vent these terrific seizures. 

GENERAL TREATMENT 

It is evident that the treatment of the epileptic 
cannot be successful unless the etiologic factor in the 
individual case is determined and eradicated if possi- 



438 CONSTIPATION IN EPILEPSY 



dbe 

n m 



bie. A study of all possible cerebral causes should 
made, including roentgenograms of the skull taken in 
various positions. If the history of the case or the 
roentgenograms show that operations on the cranium 
are likely to be of value, expert cerebral surgery 
should be done. 

Roentgenograms should be taken of the intestine 
after bismuth feeding. Finally, the patient should be 
studied psychically. The greater the hereditary ten- 
dency to the disease," probably the worse generally is 
the prognosis of entire recovery. Permanent incura- 
ble lesions in the brain or meninges make the prognosis 
bad. The importance of intestinal stasis causing 
absorption of toxins and the curability of such stasis 
medicinally, mechanically or operatively should be 
emphasized. The necessity of psychic study and 
psychic treatment of epileptics should also be realized. 

The necessity of epileptic colonies and public insti- 
tutions for the study and care of epileptics is now 
being recognized, and they have been inaugurated by 
a number of states. The importance of good, clean 
air, of outdoor work, or of indoor work under the best 
hygienic surroundings, has been shown to diminish the 
number of epileptic attacks. It is also well known 
that such patients as are not idiotic will care for each 
other during an epileptic attack ; therefore the nursing 
care of these patients in detention colonies is not great. 

Constipation must be prevented, and the'diet should 
be such as to cause the least possible production of tox- 
ins in the intestine. Generally, the lower the meat diet, 
the better for the patient, and all foods that contain 
large amounts of nuclein bodies, such as sweetbreads, 
liver, shad roe, etc., should be tabooed. Milk, eggs, 
fresh fish, peas, beans, vegetables, cereals and fruits 
make the best food for the epileptic. It is wise, when 
there is an opportunity, to individualize a patient's 
diet by ascertaining, under the different foods, the 
character of the digestion, by examining the twenty- 
four hours' urine and the twenty-four hours' feces ; but 
in public institutions where a large number of epilep- 
tics are handled, such examinations are almost impos- 
sible. The determination of the amount of indican 
in the urine, however, is indicative of the amount of 



DRUGS IN EPILEPSY 439 

intestinal indigestion, and indican in the urine in any 
amount should cause a change of diet and the admin- 
istration of foods or drugs that will cause more pro- 
fuse movements of the bowels. 

Several observers have reported marked improve- 
ment when the use of sedative drugs was combined 
with a salt free diet continued over a long period of 
time. 

It has frequently been noted that epileptic attacks 
may occur in women at the time of the menopause, or 
in girls and young women when there is amenorrhea or 
delayed menstruation. The cause has been thought to 
be due to an intoxication caused by the changed metab- 
olism, due either to insufficient elimination of nitroge^ 
nous waste products by menstruation, or due to a rela- 
tive insufficiency of the thyroid gland at these times, 
and the thyroid is known to have detoxicating power. 
This inference has been borne out in many instances 
by thyroid feeding diminishing the number of epileptic 
attacks, and even curing some cases. It is possible in 
this polyglandular disturbance of ovaries, corpora 
lutea and thyroid that the pituitary gland becomes 
involved, and its disturbance may cause the epileptic 
attacks. Focal infections, especially of the mouth, may 
be a cause of epilepsy, hence they should be sought and 
removed. 

MEDICINAL TREATMENT 

If the patient has an aura preceding his attack, he 
may be provided with pearls of amyl nitrite, N as it has 
been found in some instances the attack may be 
aborted by the inhalation of this substance. 

As constipation and intestinal intoxication seem to 
be important factors in the course of this disease, laxa- 
tives should be used as indicated by the patient's 
condition. It may be advisable to cease feeding for 
several days, as is done in diabetes, and then gradually 
evolve a diet under which the patient shows symp- 
tomatic improvement. 

Since Laycock, more than fifty years ago, introduced 
the bromid treatment of epilepsy, no other drug has 
been found more efficient in controlling the seizures. 



440 BROMIDES IN EPILEPSY 

It probably is not often true that a combination ot 
several bromids acts better than one bromid. The main 
point to remember, as so well emphasized by Clark, is 
that bromids may do a great deal of harm as well as a 
great deal of good. Sodium bromid can probably be 
taken longer without causing harm than can potassium 
bromid. There is no possible advantage of strontium 
bromid over sodium and potassium bromid ; it is more 
expensive, but is absorbed less rapidly, and more of it 
is probably lost in the intestinal canal. This has 
caused the belief that strontium bromid causes less 
unpleasant symptoms than either sodium or potassium 
bromid. If the dose of either of the last two is 
reduced, the unpleasant symptoms will be no more in 
evidence than with strontium bromid. Ammonium 
bromid is intensely disagreeable to take, and has no 
advantage over the sodium and potassium bromid. The 
other bromids are not worth mentioning. Calcium 
bromid and zinc bromid are entirely unnecessary drugs. 

The enormous doses of bromids given not only do 
harm, but also are entirely unnecessary, and it is 
probably a fact, the same as is true of enormous doses 
or iodids, that only a certain amount will be absorbed 
and circulate in the blood; the large residue of enor- 
mous doses of salts passes out of the system unutilized. 
It has also been well proved that if sodium chlorid is 
partially or entirely removed from the diet, smaller 
doses of bromid are effective, because they are 
absorbed more readily and act when there are less 
salts in the system. The smaller the dose of bromid 
that will cause a diminution in the number of epileptic 
attacks, the less is the nutrition of the body disturbed, 
the less are the internal secreting glands disturbed, 
the less are the blood-forming organs disturbed, the 
less the skin is irritated by the bromid, and conse- 
quently the less are eruptions likely to occur, and the 
less the kidneys are disturbed by not being compelled to 
excrete large amounts of salts. 

It should once more be emphasized that the adminis- 
tration of bromids will probably always reduce the 
frequency of the attacks, and in some instances may 
apparently cure epilepsy; but this symptomatic treat- 
ment is always to be regretted. In some cases due to 



HEADACHES 441 

nervous irritability when the attacks are due to some 
nervous reflex, bromids may be curative ; but the future 
of long bromid treatment means mental and physical 
deterioration. 

Most recently luminal — phenyl-ethyl-barbituric-acid 
— a drug described in New and Nonofficial Remedies, 
has been highly recommended by many neurologists, 
especially as a substitute for the bromides. The dosage 
is from 0.2 to 0.3 gm. (3 to 5 grains) several times a 
day. This dosage may be increased to 10 grains but 
should never exceed 12 grains. The drug in large doses 
kills by causing respiratory paralysis. No renal injuries 
or gastric disturbances have been observed following 
its employment. 

HEADACHES 

The causes of headaches have been divided by 
Osborne into several large classes: toxic, circulatory, 
local and reflex. 



TOXIC 


LOCAL 


Fever 


Eye inflammations 


Auto-intoxication 


Frontal sinusitis 


Intestinal 


Ethmoiditis 


Kidney insufficiency 


Ear inflammations 


Liver insufficiency 


Meningitis 


Thyroid disturbance 


Exudates into the ventricles 


Drugs 


Changes in the cerebral 


CIRCULATORY 


vessels 


Valvular disease 


Tumors 


Venous congestion 


Syphilis 


Plethora 


REFLEX 


High tension 


Eye-strain 


Arteriosclerosis 


Nasal disturbances 


Anemia 


Aural disturbances 


Leukemia 


Facial neuralgias 


Lung consolidation 


Uterine displacements (?) 


Diminished aeration 





In the first three classes mentioned by Osborne, any- 
thing that removes or corrects the serious underlying 
condition will remove the headache of which the 
patient complains. It is in the fourth class, Osborne 
believes, that a failure of diagnosis of the cause is most 
frequently made, and it is this class that constitutes 
about 90 per cent, of all cases of headache that come 



442 EYE-STRAIN HEADACHES 

to the physician. It is his belief also that 90 per cent, 
of this fourth class suffer from headache because of 
some ocular trouble. 

EYE-STRAIN REFLEXES 

The most constant condition caused by eye-strain is, 
of course, the headache. This headache may develop 
slowly or rapidly, may be centered in one eye, one side 
of the forehead or one side of the head, or may be 
referred to both eyes. In fact there is no part of the 
head that may not ache from eye-strain. Very fre- 
quently, however, one eye is more likely to be affected 
than the other, and one eye is likely to be unlike the 
other eye and be more defective than the other eye. 
Astigmatism and far-sightedness, or both, are the most 
frequent causes of eye-strain headache. Weakness of 
the ocular muscles is another cause. 

The pain is perhaps most frequent in the supra- 
orbital region, but is often in the temple, and may be 
frequently referred to the inner angle of the eye, espe- 
cially if there is astigmatism. It perhaps occurs very 
frequently in this region on account of the overactivity 
of the superior oblique muscle which endeavors to 
overcome an astigmatic mistake. Headaches from 
defective vision from any reason, and especially when 
a person becomes presbyopic and has not glasses to 
correct it, or at least has glasses that are insufficient 
to correct it, are more likely to be in the occipital 
region. Such headaches most frequently occur in the 
early morning, and are discovered by the patient on 
awaking. 

Eyes that are defective as ocular instruments are 
likely to be inherited, certain kinds of eyes appearing 
in different members of the family, the children suffer- 
ing the same defect from which the parents suffered. 
Some children are likely to have the headache begin 
at any age, but perhaps most frequently after a year 
or more of school work. These headaches are likely 
to come periodically, perhaps once a week, perhaps 
once in two weeks, perhaps only once a month, but 
with a constant tendency to become more frequent little 
by little. They sooner or later become a megrim, or 
migraine, which is typically a headache for a number 
of hours followed by nausea, vomiting, prostration, 
sleep, and recovery. 



HEADACHE HABIT 443 

The title given to most of these headaches by the 
laity is "a bilious attack," and the cause is attributed 
to overeating, eating at night, eating indiscriminately, 
or is attributed to particular kinds of food, which, if 
the patient is old enough to decide for himself, are 
gradually removed from the diet, until almost every 
kind of food and drink are subjected to more or less 
suspicion. He then attributes his trouble to his liver, 
or finds serious fault with his stomach. If he is con- 
stipated, he lays it to that, as he finds that after free 
catharsis, or at least after such a length of time as 
a cathartic will generally act, the headache disappears. 
He, therefore, thinks it is due to constipation. Girls 
and women with these eye defects are more likely to 
have headache before or during menstruation, and they 
attribute it to that function. Others learn that they 
get these headaches when they are overtired, mentally 
or physically. Some soon learn to become suspicious 
of their eyes on account of having a headache after 
theater-going, card-playing, car-riding, shopping, sew- 
ing, or reading too long, or, if they are office clerks, 
after an extra amount of proof-reading or of mathe- 
matical work. 

After the headache habit has once been formed a 
neurotic element enters into it, and there is likely to 
be a cyclical headache, even if the eye defect has been 
corrected, so that a patient who has the headache 
habit thoroughly formed will always have them more 
or less, at least until the eye becomes presbyopic and 
focusing for near objects has almost been abolished. 
It is also true that neurotic patients who are subject 
to high tension and nervous irritabilities are more 
likely to have headaches from slight eye defects than 
are more calm and less nervous individuals. 

All physicians now more or less recognize recurrent 
headaches as due to eye-strain, but a large number do 
not recognize that the patient may have stomach and 
heart reflexes without headache, and still due to eye 
defect. Dizziness, gastric indigestion, even nausea and 
vomiting may occur without any headache whatever 
and still be due to eye-strain. Cold hands and feet, 



444 TREATMENT OF HEADACHE 

chilly sensations, faint feelings, palpitation, and 
irregular heart and pain referred to the cardiac region 
so as to cause the patient to believe he has heart dis- 
ease, may be due to eye-strain and be corrected by 
correcting the eye defect. 

TREATMENT 

Patients with migraine are prone to become early 
victims of the nostrum promoter. The headache cures 
are as varied, if not more so, as the causes of this 
symptom. Practically all of them contain drugs of 
great toxicity or else consist of worthless mixtures 
with no appreciable effect. Recently acetylsalicylic 
acid (aspirin) has become the mainstay of the large 
group of laity who purchase headache "cures" in pref- 
erence to consulting a physician. 

In all cases of migraine treatment should consist 
of first, a sufficiency of outdoor exercise; second, a 
simple, varied, well-balanced diet; third, there must 
be free, daily movements of the bowels. 

Of those headaches due to ocular and reflex condi- 
tions, Osborne believes that nothing is more helpful 
than acetanilid. The dose should not be large and 
it is well to combine the drug with bicarbonate of 
sodium. While caffein adds to the toxicity of the 
coal-tar product, caffein has a useful action in curing a 
headache of the eye-strain class. If much of a dose 
of a coal-tar product is given, the patient should lie 
down for several hours, if possible. Otherwise, the 
cardiac depression caused by the eye reflex plus the 
depression caused by the coal-tar drug will produce 
faintness and more or less temporary debility. While 
acetphenetidinum (phenacetin) is perhaps a safer coal- 
tar drug to use, the dose must be so much larger than 
the acetanilid dose that the depression is about the 
same. With some patients antipyrin, acetylsalicylic 
acid or pyramidon works the best. Some find cold to 
the head of advantage, although with many it causes 
nausea. Others find hot applications satisfactory. 
Sometimes a hot foot-bath will change the circulation 
sufficiently to relieve the head congestion. Some 



DRUGS FOR HEADACHE 445 

patients are cold, and some feel hot, and the circulation 
on the surface of the body is likely to vary, depending 
on the intensity of the pain or the occurrence of nausea. 

Opium treatment for these headaches is undesir- 
able. On the other hand, one is often driven by the 
very intensity of the condition to the limit of medicinal 
resources, and sometimes cardiac depression is so 
serious that it becomes a question of either morphin 
or large doses of alcohol. Patients who have these 
terrible attacks frequently cannot well stand coal-tar 
products so often repeated, as, unless the dose is enor- 
mous, the result of their administration is nil. A 
morphin habit and an alcohol habit, to say nothing of 
the frequent acetanilid habit or caffein habit, may be 
acquired on account of eye-strain headaches. 

It is hardly necessary to mention the reflex head 
pain that may come from a bad tooth, from an inflam- 
mation in the antrum of Highmore or the frontal sinus, 
or from inflammations in the ear, as these diagnoses 
of causes of headache should be readily excluded. 

It should be remembered that frontal headache is 
frequently caused by syphilis. 

It should also be remembered, if there is insufficient 
pulmonary ability, whether from tuberculosis, emphy- 
sema, pleurisy with effusion, or asthma, that this lack 
of proper aeration may cause headache. 

At times gastric hyperacidity and uterine displace- 
ments may be reflex causes of headache, but such 
causes are rare. 

The wearing of heavy hats may be the cause of 
headaches in girls and young women, to say nothing 
of the pernicious spotted veil. 

FOR HEADACHE 

Gm. 

Ifc Caffeinae citratae 2| 3 ss 

Sodii bromidi 20| or 3v 

Sodii bicarbonatis j 

Acidi tartarici aa 10| 3 iiss 

M. et fac chartulas 10. 

Sig. : One powder in half a glass of water, and repeated 
in six hours, if needed. 

[In order that these powders may effervesce well they must 
be kept dry.] 



446 SCIATIC NEU1 

Or: 

Gm. 

I£ Acetanilidi 1 50 gr. viiss 

Caffeinae citratae |25 or gr. iv 

Sodii bicarbonatis 

Acidi tartaric! aa 5| gr. lxxv 

M. et fac chartulas 5. 

Sig. : One powder, in half a glass of water, every three 
hours, if needed. 

[In order for these powders to effervesce well they must be 
kept dry.] 

Or: 

Gm. 

I£ Acetphenetidini 1 50 gr. xxiiss 

Caffeinae citratae 25 or gr. iv 

Sodii bicarbonatis 

Acidi tartarici aa. 5 gr. lxxv 

M. et fac chartulas 5. 

Sig. : One powder, in half a glass of water, every three 
hours, if needed. 

[In order for these powders to effervesce well they must be 
kept dry.] 

SCIATIC NEURALGIA AND SCIATIC NEURITIS 

While the sciatic nerve or its branches may transmit 
painful sensations, the nerve itself may not always be 
affected, as pathologic conditions of the hip joint 
(arthritis, tuberculosis or tumor growth, as sarcoma) 
may cause pain down the sciatic nerve. 

As with backache, a patient who has sciatic pain 
should be carefully examined to determine, if possible, 
the cause. True sciatica is generally a perineuritis, 
from which this nerve suffers more than almost any 
other nerve of the body. Sciatica may be either acute 
or chronic. In the acute form it is perhaps the cause 
of more continuous and repeated suffering than almost 
any other curable disturbance. 

Hunt offers a classification of sciatica which sug- 
gests etiologic treatment. Unless the cause of the 
pain is removed, the nerve will continue to cause symp- 
toms. According to this classification, the causes of 
neuritis are: 

1. Intrapelvic disease, such as specific exudates within the 
pelvis, in venous congestion, pressure from a pregnant uterus, 
new growths, and a loaded rectum. 



SYMPTOMS OF SCIATICA 447 

2. Constitutional states, such as syphilis, alcoholism, etc. 

3. -Damage to the nerve trunk from injury or exposure to 
cold. 

4. Damage to the sacro-iliac joint. 

The most frequent cause of sciatica in. women is 
pelvic disturbance and pelvic pressure. In men a 
rheumatic and gouty tendency is frequently an asso- 
ciated cause, and exposure to cold seems to be a fre- 
quent exciting cause. A possibly important factor in 
the development of sciatica is the compression of the 
nerve against the tuberosity of the ischium by asym- 
metrical sitting on a hard seat. 

The disturbance of equilibrium caused by a weak- 
ened plantar arch or other foot disturbance must be 
considered, as well as the possibility i of a heavy patient 
lying in bed too long on his side, and thus causing 
pressure in the region of the hip. The springs of the 
bed and mattress, with extra pillows and cushions if 
necessary, should be so arranged as to relieve all pos- 
sible continued injury to the sciatic nerve. 

When the cause of the disturbance is considered to 
be a general one, a possible focus of infection should 
be sought. A frequent cause in adults is infection in 
and around teeth, or possibly in a tonsil. 

Besides syphilis and alcohol as causes of sciatica, 
diabetes and malarial poisoning should be considered. 
Impaired circulation in the legs, from varicose veins 
or from insufficiency of the heart, may perpetuate sci- 
atica after it has once started, and treatment in such 
instances must be directed toward improving the cir- 
culation. 

SYMPTOMS 

It is hardly necessary to refer to the symptoms of 
neuritis of the sciatic nerve. Often a patient can map 
out the course of the nerve by describing where he 
feels pain, and if not pain, where he feels twinges 
or peculiar sensations of irritation. There may be, 
after some days of a real inflammation of the nerve 
trunk, regions of paresthesia in different parts of the 
leg supplied by branches of this nerve, and still later 
there may be impaired mobility of some muscles. The 
pain may be so severe as to be tearing or boring in 



448 TREATMENT OF SCIATICA 

character, and there may be attacks of cramps or con- 
tractions of one or more muscles causing very intense 
pain. There may be some reddening of the skin along 
the course of the nerve, local elevation of temperature, 
and rarely some edematous symptoms. The electric 
excitability may be increased at first, and later dimin- 
ished. The patellar reflexes are normal at first, and 
later may be diminished. Occasionally a herpes may 
occur; there may be some local sweating, showing 
trophic disturbance. In chronic sciatic pain, the sen- 
sation may become almost a habit or a condition 
expected by the patient, so that the general neurotic 
condition must be treated more than the local pain. 

GENERAL TREATMENT 

Besides removing the cause of sciatica, if such is 
possible, the general treatment is important. The diet 
should be modified according to the general condition. 
In some instances meat should be removed from 
the diet. In other instances it should not be with- 
drawn ; in fact, protein should be pushed and nutrition 
increased. Constipation should always be prevented. 
The treatment may be started with a brisk purge, by 
castor oil or calomel. The bowels should be moved 
daily, with salines if there is plethora, overweight and 
a good heart, and with vegetable laxatives if the 
patient is underweight, anemic, or with poor circulation. 

Rest of this nerve is of primary importance, even if 
there is only a neuralgic condition, that is, an irritation 
without a neuritis or perineuritis, and it is imperative 
when there is a neuritis or perineuritis. A neurotic 
habit of the individual should always be noted. If 
such is present, this pain, like any other, will be harder 
to combat, and the main treatment should be toward 
the general condition, whether neurasthenic, hysteric 
or plainly neurotic. Like any other painful nerve, it 
must be kept warm. Warmth is one of the most 
important elements of local treatment. 

In acute inflammations of this nerve the pain is so 
excessive that generally morphin must be given. But 
before morphin is resorted to, the leg should be 
immobilized and sometimes made rigid with a long 
splint. It is generally best not to give atropin with 



LOCAL TREATMENT IN SCIATICA 449 

morphin, as atropin acts only on the peripheral endings 
of nerves, and in this case the nerve trunk is in trouble, 
and the atropin will combat somewhat the sedative 
action of the morphin. Also the morphin may have to 
be repeated more frequently than it would be wise to 
repeat the atropin. When the pain is not sufficiently 
severe to require morphin, antipyrin will sometimes act 
as a valuable sedative ; also novaspirin, especially if 
the patient is rheumatic, or atophan, of which the 
analgesic and other qualities have been mentioned else- 
where. 

LOCAL TREATMENT 

Besides the local treatment already suggested, dry 
cupping and cauterizing, and at times blistering along 
the course of the nerve, may be not only of tempo- 
rary but also of permanent benefit. Sometimes the 
d'Arsonval current or diathermy is of benefit in sub- 
acute and chronic cases. Sooner or later, gentle mas- 
sage is of benefit. 

When this nerve is somewhat stretched and at rest, 
especially when the leg is surrounded by dry heat, as 
by hot sand bags or other methods of applying heat, 
excruciating pain may entirely cease. Such patients 
are fortunate, as narcotics need not be given. 

If there is a rheumatic condition present, large 
doses of salicylates are of benefit. Alkalies are fre- 
quently of service, such as potassium citrate in 2 gram 
doses, in wintergreen water, given three or four times 
in twenty-four hours. If there is nervous irritability 
and considerable cerebral irritation, bromids are of 
value, but they should be soon discontinued, as they 
interfere with nutrition and are very depressant, and 
calcium should be substituted. 

Sometimes warmth is well applied to this nerve by 
a cradle containing electric lamps, and the leg is sub- 
jected to this kind of heat and the resulting local 
sweating once or twice a day for from fifteen minutes 
to half an hour. 

High-frequency currents have been applied to this 
painful nerve, sometimes with good results ; but often 
electricity in any form is not well tolerated, however 
diathermy may be of great benefit. 



450 NERVE INJECTIONS 

Ethyl chlorid spray along the course of the nerve 
or in different painful regions of the nerve has been 
reported to be successful in modifying the pain. Epi- 
nephrin ointments have been gently rubbed into the 
skin along the course of the nerve with some success. 

Salt solutions, cocain solutions and beta-eucain solu- 
tions have been injected around the nerve sheath in 
prolonged acute and subacute cases, with considerable 
success. The injection treatment with sterile water or 
sterile physiologic saline solution is an old treatment, 
recently revived. This treatment is not advised in 
every case of sciatic pain, as many individuals are 
benefited and recover with ordinary local and constitu- 
tional treatment; but when the inflammation and pain 
persist, it is perhaps the most successful treatment. 
The technic is very difficult and usually best left to the 
specialist. 

Beta-eucain has been used as an infiltration injec- 
tion in strength of 0.1 per cent, solution and 100 c.c. 
in bulk. Cocain has been used in 1.5 per cent., 2 c.c. 
in bulk, followed by 100 c.c. of physiologic saline solu- 
tion. 

Injections of small bulk into the sheath of the 
sciatic nerve, called nerve blocking, have been done 
frequently in the severe forms of sciatica. A hypo- 
dermic syringe full of plain, cold water has been used, 
also cocain solutions, and sometimes morphin solutions. 

Whatever injection treatment is done, the treatment 
should be considered radical, and should be done by one 
who has become proficient in this operative therapy, 
as sometimes uncomfortable symptoms are developed. 

The injection of alcohol has been shown by Cad- 
walader to be unjustifiable, as alcohol destroys nerve 
tissue. He found that salt solution injection into the 
sciatic nerve did not cause any degeneration, while 
strong alcoholic solutions caused destruction of nerve 
tissue. 

Rosenbeck and Finkelstein found that only 20 per 
cent, of patients with sciatica could be relieved by 
injections into the nerve or its sheath. 

Stretching the sciatic nerve has been recommended 
for many years, and is sometimes of great value in 
relieving pain, especially if the nerve and leg are then 



BRACHIAL NEURITIS 451 

put at rest, allowing the inflammation to heal. This 
may be done nonoperatively, by extending the leg in 
various directions and thus stretching the nerve. 

BRACHIAL NEURITIS 

Brachial neuritis may be produced by any of the 
chronic constitutional poisons, such as lead, arsenic, 
alcohol or tobacco; by uric acid disturbances; by 
altered metabolism of proteins ; by insufficiency of the 
kidneys, by diabetes and by mouth infection. It may 
occur also from straining or injury to the brachial 
nerves or the brachial plexus. Lying on the arm at 
night frequently produces a brachial neuritis. The pain 
is particularly severe in the neuritis occurring in dia- 
betes, but it may be severe from any cause. Pain 
shooting down the brachial nerves may be due to pres- 
sure from neighboring structures, as when there are, 
rudimentary cervical ribs, or a subdeltoid bursitis. 

The primary treatment depends on the etiology, and 
as in sciatica and in backache, a complete history 
should be secured and a careful examination of the 
patient should be made to determine the predisposing 
or exciting factor. This should be removed if pos- 
sible. When the neuritis is due to some general poi- 
soning, and perhaps always unless the patient is 
greatly debilitated, purging on several days, or alter- 
nate days, with a complete change in the diet, is a 
beginning treatment that may be valuable. Anything 
that causes pressure or injury to the brachial nerve or 
the brachial plexus must be removed before treatment 
will be at all successful. Any occupation or use of the 
arm that perpetuates the trouble must cease. 

In rheumatic and related conditions, a course of 
sodium salicylate followed by a course of alkalies in 
conjunction with a vegetable and cereal diet will often 
be of rapid benefit. 

If the pain is so severe as to prevent rest and sleep, 
the temporary use of narcotics may be necessary, and 
some hypnotic, as chloral or the bromids, is often 
advisable, at least for a short time. One of the coal- 
tar products may be of value. None of these depres- 
sants, however, should be long continued. 



452 BRACHIAL NEURITIS 

A patient with brachial neuritis rarely needs to go to 
bed; if he carries the arm in a sling he will get com- 
fort and rest for the nerve, and have much less pain. 
The sling should support the elbow so that the arm 
will not drag on the painful muscles. At night, or 
at periods during the day, dry heat, as represented by 
an electric pad or a hot water bag, is of benefit. As 
in treating any other sore or painful nerve, the region 
should be kept warm with flannel or cotton. Some- 
times gentle stroking upward, or massage along the 
course of the nerve to promote the flow of the lymph 
in the lymph channels, is soothing and relieves local 
congestion. Later, the arm may be extended and 
stretched, by the physician, in different directions. 
This stretching of the nerve seems not infrequently to 
relieve the pain and hasten recovery. This may be 
done daily or every second day for some time. 
Between times the arm should be at rest, until the 
acute and subacute stages of the inflammation are over. 

Dry cupping of the tender nerve, especially as soon 
as the acute stage is over, is at times of benefit. 

Either the d'Arsonval or the Oudin form of high 
frequency current has been recommended for brachial 
neuritis, and sometimes lessens the pain and is of 
benefit in hastening recovery. The treatment should be 
applied locally by a glass vacuum electrode, and the 
electrode should be passed along the whole course of 
the region of pain for a few minutes at first, and not 
for more than ten minutes at any one time, at first 
daily, and later less frequently. So-called diathermy, 
electrical heat applied deeply, is of great help in quiet- 
ing and aiding recovery. 

In the recurrent deltoid muscle pains, which occur 
in some persons who have a tendency to malmetabolism 
of the proteins of meats, the vacuum electrode current 
will sometimes temporarily eradicate the pains. It may 
be used on the bare skin or through one layer of 
clothing. 

Whenever vacuum electrodes are used 'close to the 
skin, great care must be taken that burns are not 
caused. If the skin is covered, sometimes the current 
will be used longer and stronger than is intended, one 
being better able to observe on the bare skin the effect 



PAINFUL FEET 453 

of the electric current; but after one or two treatments 
of a person, the susceptibility of his skin to irritation 
will be recognized, and the dosage and intensity sub- 
sequently modified to fit the individual. 

Active massage is also of benefit in these cases, and 
the same is true of polarization with the constant or 
galvanic current for a few minutes, one electrode being 
indefinite, and the other, generally the negative, being 
active over the muscle for a few minutes. 

When all acute symptoms of neuritis have disap- 
peared, or the acute pain and inflammation in a muscle 
have disappeared, and yet recurrent aches occur, with 
more or less impaired motility, massage and mechani- 
cal vibrations are of value in completing the cure. If 
there is paresis or semiparalysis of one or more mus- 
cles, electric treatments are essential, or if the shoulder 
joint has become more or less impaired in its motion 
and function by the long continued inactivity, or adhe- 
sions have actually formed from the joint not having 
been properly used, active breaking up of the adhe- 
sions must be done. If too painful, this may be done 
rapidly under anesthesia ; or less active, but repeated 
passive motion of this joint must be caused, tending 
to gain increased motility day by day until the joint 
becomes normal. The patient should also daily use 
the arm to a certain extent and then rest it, if neces- 
sary in a sling, for the remainder of the day, until he 
is able to use the arm for his duties without causing 
continued pain afterward. 

PAINFUL FEET 

This troublesome subject has been discussed by many 
writers as a separate disease condition. Of all the 
orthopedic ailments affecting mankind, it is perhaps 
most usual for him to suffer with painful, aching 
feet. Frauenthal has suggested that when the pain 
comes on acutely it is due either to an injury or 
to an infection; when the pain comes on gradually, 
there is some relaxation of ligaments or supporting 
structures. He deplores the promiscuous use of foot 
plates, some of these, metal supports doing more harm 
than good. A proper fitting shoe is the first essential 
to comfort of the foot. An arch may not be broken or 
may not have fallen, and may not need a support. All 



454 BACKACHE 

it needs is a proper adjustment of the heel to the foot 
tread and a proper arch to the shoe. Also, pain in 
the forward part of the foot is often not caused by a 
weakened arch, and an arch support will not correct 
pain in other weakened joints or ligaments. On the 
other hand, when the arch has fallen or has become 
weak, and there is a rotation of the ankle inward, 
besides a proper fitting shoe a plate or support that fits 
the foot and corrects the deformity may and will often 
entirely relieve the pain in the foot and the associated 
pain of the leg and back. Various exercises of the 
foot muscles may strengthen the arch and later allow of 
the removal of this artificial support. 

Another frequently overlooked cause of sore feet and 
pain and tenderness of the ball of the foot is the 
modern craze for dancing. A few anatomists call 
attention to sesamoid bones as being normal in this 
region of the foot and especially likely to be present 
at the metatarsophalangeal joint of the great toe, 
namely, the ball of the foot. 

By a series of roentgenograms of normal feet and feet 
that are painful in this region, Barnes has found that 
the sesamoid bone is part of Nature's method of pro- 
tecting this joint and causing normal tread and normal 
support. He also finds that this sesamoid bone may be 
fractured or may become injured and not only cause 
pain from its own disturbance, but cause pain in the 
joint above it. He orders shoes made with a depres- 
sion in this region of the sole, and causes comfort, and 
cures his patients of their disability. In acute injuries 
of this region nothing will be of so much benefit as 
rest. 

At times irritation or injury may cause an exostosis 
to occur in this region, which of course can be cured 
only by surgery. 

BACKACHE 

The therapy of backache may belong to the domain 
of the neurologist, the surgeon, the gynecologist or the 
genito-urinologist. Backache is a common symptom 
of innumerable disorders. It can be treated rationally 
only after the correct diagnosis is made. Unless this 
is done, any improvement resulting from the treat- 
ment is similar to that following any hit-or-miss thera- 
peusis. 



CAUSES OF BACKACHE 455 

DEFINITION 

By backache is usually meant lumbar pain begin- 
ning at the region of the first lumbar vertebra and 
extending downward, often to the sacral and coccygeal 
regions. The pain may be in the center of the back, 
along the spine, or on either one or both sides of the 
spine. 

ETIOLOGY 

Often the clue to the real cause of the pain may be 
obtained by careful questioning. The duration and 
nature of the pain, its exact location, whether in the 
center or to one or both sides of the spine, are all of 
importance. It is essential to know whether or not 
the pain is associated with fever; has followed a con- 
valescence from some infection ; is associated with pain 
on urination or with changes in the appearance of the 
urine; has followed a sudden strain; is aggravated by 
bending the body in any direction, or has any rela- 
tionship to menstrual or uterine disturbances. 

After a careful history of the patient has been 
recorded, a thorough physical examination is essential 
in the search for the etiologic factor in the back- 
ache. On account of the large number of varied 
causes, treatment without examination is generally 
guesswork. The best way to examine the patient is 
to remove his clothing, and to observe him first in the 
standing position, noting whether or not the body is 
flexed to one side or the other, or more weight is 
placed on one leg than on the other. The presence of 
any abnormal curvatures or deformities of the spine, 
or any enteroptosis should be noted. In palpating, 
points of tenderness should be sought over the spinous 
processes of the vertebrae, and the presence of ptosed 
or enlarged abdominal organs should be noted. In 
women a vaginal examination is essential for the detec- 
tion of any abnormal uterine conditions, such as 
marked retroversion or tumors of the uterus, or any 
pelvic exudates or abnormalities. The patient should 
flex the body in various directions while in a standing 
position and should be requested to flex and extend 
the thighs on the abdomen while lying on the back, 
that the freedom of these motions and the amount of 
pain they cause may be noted. 



456 BACKACHE DUE TO LACK OF BALANCE 

Roentgen-ray examination of the spine will often 
be of service in revealing thickening or ankylosis of 
the vertebral joints or rarefaction of the bodies of the 
vertebrae. It will also aid in helping to exclude renal 
or ureteral calculi. Finally, the temperature and 
urinary findings may aid in deciding the cause of the 
trouble. 

BACKACHE DUE TO STRAIN OR LACK OF BALANCE 

By far the greatest number of backaches belong to 
the fatigue and lack of balance group. This group 
has been described by Reynolds and Lovett as due to 
loss of balance, when an unusual strain is placed on 
the lumbosacral tissues and the muscles of this region. 
The strain may be produced by posture, by poor mus- 
cular balance and by abnormal conditions within the 
abdomen, such as enlargement of the organs, enterop- 
tosis and obesity. The fatigue may result from an 
attitude constantly assumed in some form of occupa- 
tion, such as stooping or bending, or by lifting heavy 
objects. 

Those backaches resulting from changes in muscular 
balance due to uncorrected broken or fallen arches of 
the feet, or to the continuous use of poorly fitting 
shoes, are also placed in this group. The pain in these 
cases often extends up the lower extremities to the 
back. From a faulty tread, the muscles of the leg, 
thigh and lower part of the body may be strained and 
become painful, and even the knee joint or hip joint 
may be strained by the lack of balance. A careful 
examination of the shoes, feet, and posture on standing 
and walking, and an investigation of the kind of work 
or the kind of strain to which the patient is subjected, 
will generally disclose the physical cause and the con- 
sequent treatment of this kind of backache. 

As a result of the constant backache or frequent 
attacks of backache, there may come a time when, in 
the highly neurotic individual, the mind is fre- 
quently concentrated on the back, and as a result 
pains will be present without any cause. Associated 
with this may be other symptoms, such as perverted 
heat and cold sensations, an abnormal state of the 
reflexes indicating a neurasthenic tendency. This con- 



INFLAMMATION OF NERVES 457 

dition has been termed "hysterical spine" or, after 
railway accidents, "railway spine." 

The treatment of this form of backache will tax the 
energies of the therapeutist. No definite rules can bt 
laid down, except that all other possible causes of the 
backache must be excluded before a diagnosis of 
hysterical or railway spine is made. In these cases, 
treatment should be mainly general, and should be 
based on efforts to relieve and cure the neurotic con- 
dition of the patient. Local treatment is generally only 
of psychic value, but for that reason alone is essential. 
In local treatment, use may be made of electricity, 
diathermy, vibrations, electric light heat, spinal douches, 
or other hydrotherapeutic measures, and even at times 
the thermocautery will be found of value. Hypodermic 
injections of water into the painful regions may be 
efficient. The general treatment calls for increased 
feeding, general massage, and regulated exercise, with 
periods of rest. Occasionally, tonics may be indicated. 

BACKACHE DUE TO INFLAMMATION OF NERVES 

To this type of backache belong those due to affec- 
tions of the nerves or to affections of the posterior 
nerve roots with their nerves. This includes neuritis, 
simple or part of a multiple neuritis, resulting from 
alcoholism, lead or diabetes. Removal and elimina- 
tion from the system of the alcohol or lead is the first 
aim of treatment in the first two instances, and the 
pain will be ameliorated by proper diet in the case of 
diabetic neuritis. 

The acute pain of the neuritis must be stopped, and 
if local sedatives, as heat, rest and support by straps 
or otherwise, do not give immediate relief, a drug 
sedative must be given, with the full recognition of the 
probable prolonged or recurrent backache being likely 
to cause repeated need for the narcotic, and hence the 
danger of the formation of a drug habit. Occasion- 
ally the pain is so severe that morphin with atropin 
must be given; the latter dulls the endings of the 
peripheral nerves. If the pain is not so severe, or if 
it is modified by one or two hypodermics, then large 
doses of sodium salicylate may be tried, as 1 gm. once 
in four hours for a few doses. In some instances large 



458 BACKACHE DUE TO INFECTION 

doses of quinin may be efficient, as 0.4 gm. three times 
a day for a few doses. If either a salicylic preparation 
or quinin is pushed to physiologic effect, a bromid 
should be given synchronously to prevent the uncom- 
fortable salicylism or cinchonism, respectively. Five- 
tenths gm. of sodium bromid may be given for each 
gram of salicylic acid, and 1 gm. of sodium bromid 
for each 0.3 gm. of quinin. When there is insomnia 
without severe pain, chloral in doses of from 0.5 to 
0.6 gm. may be given at bedtime. Sodium diethyl- 
barbiturate (veronal-sodium) in doses of 0.3 gm. may 
be given for sleep, if there is no severe pain. Locally 
to the back, gentle high-frequency electric currents 
may be tried, or the arc lamp treatment, with later 
dry cupping, and perhaps the thermocautery. 

In posterior ganglionitis with herpes, if there is con- 
siderable pain, the treatment may be much the same as 
in simple neuritis. If the pain is not too severe, a 
narcotic is not needed. Generally rest and soothing 
powders and absorbent cotton placed over the erup- 
tion, with supporting adhesive straps to limit motion, 
markedly ease the pain. 

BACKACHE DUE TO INFECTION 

A large number of backaches are due to changes in 
the bodies of the vertebra or in the intervertebral 
joints. When the joints are involved, the pain may 
be due to an acute infectious arthritis or to chronic 
hypertrophic arthritis (ostearthritis). These are both 
associated with a primary focus elsewhere; the acute 
condition may be part of an acute infection, such as 
acute follicular tonsillitis, tooth infection, pneumonia, 
gonorrhea or influenza. When these causes are present 
there will also be symptoms of the primary infection, 
such as more or less increased temperature. The 
involved portion of the spine may be exceedingly ten- 
der. Generally this kind of backache disappears with 
the subsidance of the primary infection. 

Hypertrophic arthritis (ostearthritis) is a slowly 
developing process, often lasting several years and 
resulting in a thickening, and sometimes in a union 
of the vertebrae and cartilages. It is caused by a con- 
stant source of infection, the commonest being 



BACKACHE DUE TO INFECTION 459 

repeated tonsillar infections, pyorrhea alveolaris and 
chronic gonorrhea. It may be associated with an 
arthritis deformans of the extremities. The diagnosis 
is assisted by roentgen examinations of the spine. 

The treatment consists in removal of the primary 
source of infection, if it can be located. Large hyper- 
trophied tonsils should be removed, and alveolar pyor- 
rhea should be treated. An abscess in or around the 
roots of the teeth should be sought by means of roent- 
genograms, and if an infected tooth is found it should 
be removed or properly treated. 

If there is any history of a former venereal infec- 
tion, in the male, a careful examination should be 
made of the deeper urethra, the prostate and the asso- 
ciated organs, and any part found infected should 
receive proper treatment. In females pelvic disease, if 
present, must be removed, if possible. 

Vaccines have sometimes been found of value, espe- 
cially when they have been prepared from organisms 
isolated from a primary focus. Until the source of 
infection is eradicated, local treatment of the back is 
discouraging, although some relief from the pain may 
be given by applications of heat, counterirritation and 
strapping. 

Two common causes of infection of the bodies of the 
vertebrae are tuberculosis and typhoid fever. In 
tuberculosis the backache first manifests itself when 
the destruction has progressed to such an extent that 
a gibbus, or bending, of the spine has resulted, and 
with it pressure on the nerves has occurred. In the 
treatment of this condition, spinal support and spinal 
rest, as furnished by a brace or a plaster cast, should 
be used. Later, after the disease has become quiescent, 
the destroyed bone tissue may be successfully repaired 
by plastic bone surgery. 

The socalled typhoid spine occasionally develops 
after convalescence from typhoid fever. The pain is 
localized, and may become severe. It does not pro- 
duce angulation and the deformities characteristic of 
tuberculous involvement of the spine. The spine is 
rigid and very tender, and there is often more or 
less fever. The condition is, as a rule, self-limited, 
and with proper rest and simple local and general mea- 
sures, usually results in recovery. 



460 SACRO-ILIAC STRAIN 



SACROILIAC PAIN 



Lumbago, lumbosacral nerve pains, uterine displace- 
ments, coccyodynia or coccyalgia, hemorrhoids and 
bone disease or bone tumors are not now a sufficient 
diagnosis to account for all the kinds of backache of 
the lower part of the spine. Orthopedists have long 
shown that backaches may come from weakness or 
broken arches of the feet, as suggested above, throw- 
ing the whole center of gravity so far off as to cause 
pain in the muscles of the back in the effort of these 
muscles to keep the body in proper equilibrium. They 
are now teaching the practicing physician, the gyne- 
cologist and the surgeon that many backaches are due 
to a relaxation of the sacro-iliac joints, to inflamma- 
tion in these joints, and sometimes to degeneration of 
the bones of these joints. This kind of backache 
occurs most frequently in women. 

It was long believed that the sacro-iliac joint was not 
intended to have much motion. It has been learned, 
however, that it has a very valuable and necessary 
function, and when disabled causes symptoms. These 
joints may suffer from arthritis due to an infection, 
rheumatic or otherwise. They may be disturbed by 
faulty posture or position, as suggested above. They 
often become more or less permanently injured, owing 
to a relaxation of the ligaments of the joint, often due to 
long continued lying in bed, whether from a long illness, 
as typhoid fever, or after surgical operations, or from 
other illness which means much or continued lying on 
the back. Consequently, any patient who must be 
long recumbent must be frequently turned, if possible, 
and the bed must be flat and must not be allowed to 
become sunken in the center. Many an otherwise 
well person has iliosacral and lumbosacral backaches 
simply because his bed is too soft and the springs have 
relaxed, and he lies all night as one would in a ham- 
mock. Many an instance of this kind of backache will 
be entirely cured by a stiffening of the springs, or a 
change of bed. 

These joints may be strained by a sudden twist or 
turn, or by direct injury in this region. Many a lumbo- 
sacral backache dates from an operation table, when 
the patient was long in an obstetric or lithotomy posi- 



SACRO-ILIAC RELAXATION 461 

tion. Great care should always be exercised during 
these prolonged operations that the legs are occasion- 
ally moved and not allowed to hang in a position that 
is of great disadvantage to the iliosacral joint. Some 
orthopedists believe that these joints may be injured 
by lifting a heavy object; others do not believe that 
they are thus injured. Lovett does not believe that a 
strain of this joint is thus caused, but considers it 
always an attitudinal strain due to faulty positions and 
fatigue. Patients with this kind of backache often 
hold themselves more or less rigid while walking, thus 
tiring other muscles. They dislike to jar themselves, 
and the pain may radiate down the gluteal muscles into 
the thighs, or there often seems to be an associated 
sciatic nerve pain. In fact, many a case of sciatica is 
not benefited until a defective sacro-iliac joint is 
improved. 

A lumbago or pain in the lumbar muscles, that is, 
a myalgia of the lumbar muscles, will respond readily, 
as a rule, to a diet without meat or a diet limited to 
milk and cereals, with plenty of water, and with the 
administration of alkalies, such as potassium citrate, 
2 gm., in wintergreen water, administered three or 
four times in twenty-four hours, and to massage and 
local heat. But if the pain is due to a weakening of 
the sacro-iliac joint, none of these treatments will be 
curative. 

The only treatment which is of any avail in sacro- 
iliac relaxations or weakened joints is afforded by 
more or less immobilization by strapping over the 
sacro-iliac region, unless the patient rests in bed on 
a stiff mattress. The straps of adhesive plaster may go 
all the way round the body at the level of the upper 
part of the ilium, and may cross each other over the 
sacrum ; or they may be run diagonally from just below 
the brim of the pelvis around and across the back. 
Each strap should overlap the other from a third to 
half of its width to cause good firm support. When 
diagonal straps are used, a firm supporting strap of 
adhesive should be put all the way round the pelvis. 

The straps being of benefit to a person, later a 
proper kind of corset may be made, in the case of a 
woman, or a proper kind of supporting belt in the case 
of a man, for permanent use. 



462 LUMBAGO 



LUMBAGO 



While most of these backaches of the lower part of 
the spine were long attributed to lumbago or myalgia 
of the lumbar muscles, we are now learning that only 
a small proportion of backaches in this region are due 
to this cause, and Lovett, in a study of eighty-three 
cases of backache, found only one due to lumbago. As 
just suggested in discussing the diagnosis of lumbago 
from sacro-iliac joint pain, the treatment there out- 
lined for lumbago is almost invariably successful. Hot 
water applications are also of value, and especially hot 
sitz baths followed by deep massage. If the patient is 
rheumatic and has had joint pains, the salicylates may 
be given. Temporary strapping of the back up and 
down the spine, or in such a way as to relieve the 
affected muscles, always causes comfort, hastens recov- 
ery, and allows the individual to get about sooner than 
when strapping is not done. Electrical and vibratory 
treatments, and deep massage, are also of much value. 

BACKACHE DUE TO PELVIC CONDITIONS 

Women with disorders of the pelvic organs fre- 
quently complain of backache. It is often associated 
with painful menstruation, and is undoubtedly due to 
either the increased congestion in the pelvis or to an 
obstruction to the passage of the blood at the cervix 
uteri. Retrodisplacement may produce backache in the 
sacral region, but the amount of displacement is no' 
index to the amount of pain they will suffer. Backache 
can be absent in marked retroversion, but is likely to 
be present if there are many adhesions. Cervical ero- 
sions and lacerations, inflammation of the uterus and 
ovaries, and tumors of the uterus and ovaries may all 
be causes of lumbosacral, but principally sacral, back- 
ache. 

It is hardly necessary to declare that no lumbosacral 
backache in a woman should be treated without a care- 
ful pelvic examination having been made. A correction 
of any malconditions found will be the only means of 
relieving such a backache. However, it should not be 
forgotten that a patient may have other causes of lum- 
bosacral backache, even if a pelvic disturbance is pres- 



BACKACHE AND ABDOMINAL CONDITIONS 463 

ent. Consequently, the same physical examination of 
the feet, legs and back should be made as though no 
pelvic disturbance were present. 

BACKACHE DUE TO ABDOMINAL CONDITIONS 

Pathologic conditions of the kidney may cause pain 
to be referred to the lumbar region. The most fre- 
quent kidney causes are calculi, pyonephrosis, peri- 
nephritic abscess, new growths and floating kidney. 
While many floating kidneys cause no symptoms, some- 
times a kidney that is only slightly loose may cause 
distinct symptoms and pain referred to the back. 
Examinations of the urine, especially when obtained 
by catheterization of the ureters, will reveal the pres- 
ence or absence of pus, and generally of a calculus, 
and roentgenoscopy will almost always clear up the 
calculus question. If a calculus is present in the pel- 
vis of the kidney causing backache, pain will also be 
generally referred down in the direction of the ureter 
to the bladder, and in the male to the testicle, which 
immediately shows that the backache is purely sec- 
ondary to the other condition. A constant study of all 
the urine passed for a few days, and observation of the 
temperature, will reveal the presence of pus in the 
kidney. The treatment of these conditions is, of 
course, surgical. 

A floating kidney causing pain may be kept in posi- 
tion by a proper abdominal belt. If it still causes pain 
and symptoms, it should be fixed by operation. 

A pendent or very obese abdomen may cause the 
patient so to change his normal posture as to produce 
backache. Abdominal supports will help in such a 
case. Ptosed abdominal organs may cause such drag- 
ging on ligaments as to give backache ; again, abdom- 
inal bandages and proper supporting corsets will 
relieve the strain on the back muscles, allowing the 
patient to assume a more normal posture while walk- 
ing and standing. 

Impacted feces in the colon, abdominal and rectal 
growths, and syphilis of the spine are all occasionally 
causes of backache, and, of course, except in syphilis, 
treatment of the back is futile. 



464 NEURASTHENIA 

NEURASTHENIA 

The suggestion that neurasthenia, like hysteria, 
needed explanation, and that many of the symptoms of 
this condition could be explained by a subsecretion^of 
the suprarenals was made by Osborne {Jour. A. M. A., 
March 23, 1901, p. 796) in several discussions on 
the subject of internal secretions, and was distinctly 
described by the same author {Jour A. M. A., Feb. 
26, 1910, p. 670) in an article in which he says, "It 
is possible that neurasthenic conditions and condi- 
tions of chronic low blood pressure, without tangible 
circulatory excuse, may be due to an undersecretion 
of the suprarenals." It must be allowed that physical 
tire may cause circulatory weakness and prostration, 
and that mental tire may cause sleeplessness, loss 
of appetite, and thus a marked insufficiency in the 
recuperative power of the body without, perhaps, 
any special disturbance of any organ or gland. On 
the other hand, persons who are always neurasthenic, 
always subnormal, without any special disease, should 
be subject to classification even more readily than is 
the neurotic individual. The typical neurotic gen- 
erally has, if not always, disturbance of the thyroid 
gland. The typical neurasthenic probably generally 
has disturbance of the suprarenal gland on the side of 
insufficiency. The blood pressure in these neuras- 
thenic patients is almost always low for the individuals, 
and their circulation is poor. Often the activities of 
the internal organs are impaired, although there may 
be no discoverable organic disease. Mental exertion, 
even the simplest, often causes so much weariness and 
exhaustion as to be prohibitive; that is, such exer- 
tion must be forbidden. A vasomotor ataxia, often 
present, allows chillings, flushings, cold or burning 
hands and feet, drowsiness when the patient is up, 
wakefulness on lying down and hence insomnia. The 
nutrition may be fair or even good, and the weight 
may be normal. There may be more or less tingling 
or numbness of the extremities. 

There is not much doubt that the cause is distur- 
bance of one or more internal secretions, but just 
which glands are at fault is difficult to determine. 



CAUSES OF NEURASTHENIA 465 

Testicular and ovarian disturbance, especially on the 
side of deficiency, are known to cause general depres- 
sion, hysteria, hypochondriasis, melancholia and dis- 
turbances of the digestive secretions. A disturbance 
of the thyroid secretion may cause in one patient hys- 
teria and in another patient depression; or both con- 
ditions may occur in the same patient at different 
periods. That very large mammary glands, in women 
who are not pregnant and who are not lactating, may 
disturb the system has not yet been proved. Many 
girls and women, however, who are not well and 
strong, whose flesh is flabby, who may either be over- 
weight or underweight, and who have the mammary 
glands excessively large, may be disturbed by an 
internal secretion of which we as yet know little. 
Pituitary disturbance may affect the cerebral activity. 

Many of the symptoms of physical and mental tire,, 
with low blood pressure, especially if accompanied by 
increased pigmentation anywhere on the skin, may be 
due to insufficiency of the suprarenals. 

Williams (Jour. A.M. A., Dec. 19, 1914, p 2203) 
comes to the conclusion that many patients who pre- 
sent the well known symptoms termed "neurasthenia" 
with low blood pressure, with loss of mental elas- 
ticity, with both mental and physical depression, with 
the fear that they cannot now accomplish their usual 
good mental work, with the story that they have "lost 
their nerve," in the phraseology of the times, with the 
fearfulness of making wrong decisions, and with a vas- 
dilating and indecisive frame of mind, are many 
times suffering from an insufficiency of the suprare- 
nals. He finds, as other clinicians have, that the 
administration of the dried suprarenal gland, in tablets 
of from 2 to 4 grains, two or three times a day, has 
caused improvement in many cases. 

Any sensible suggestion is worthy of trial in this 
troublesome neurasthenia, especially as such patients 
readily acquire the sanatorium habit and become more 
depressed. Physical and healthy mental exercise is 
good for these patients. Generally an increased pro- 
tein diet does them good, as many of them have been, 
for one reason or another, reducing their meat, fish 
and egg intake. 



466 TREATMENT OF NEURASTHENIA 

Riggs {Johns Hopkins Hosp. Bull, 1916, 24, p. 281) 
is convinced, and he is right, that in these cases pro- 
longed rest has done more harm than good. Riggs 
believes that neurasthenia is primarily a mental dis- 
order ; that the disorder, in nearly all cases, is originally 
independent of any and all bodily conditions, and that it 
exists, in spite of a structurally normal central nervous 
system. To all intents and purposes, then, the neuras- 
thenic is an originally normal individual. He is sound 
of mind and body, but this normal apparatus of his gets 
out of working order because it is unskillfully used, and, 
therefore, gets out of internal adjustment, and also out 
of adjustment with what should be its work. Were 
neurasthenia exhaustion, rest would cure it: it does 
not. Were it an inherent weakness of the organism, 
not a single case could be cured: many cases are 
cured. Were it due to physical disorders, then physi- 
cal treatment of these disorders would cure it. The 
conclusion seems clear that neurasthenia is not weak- 
ness nor exhaustion ; that it is neither a malady of the 
intestines, the heart, the stomach, nor a disorder 
dependent on structural change of the nervous sys- 
tern; and that it, therefore, cannot be cured by rest 
or by any other physical means. ,He would rely pri- 
marily on psychotherapy and reeducation. Occupation 
plays a large part and the patient's work must interest 
and please him. This whole discussion seems to show 
that the trouble is with the endocrine glands. 

It should be urged that for the supposed suprarenal 
insufficiency it is not sufficient to give the blood- 
pressure-raising substance of the suprarenals, but the 
whole gland must be fed. Just how much valuable 
activity is absorbed from the suprarenals when fed 
has not been determined. Cases are on record in 
which feeding of this gland has seemed to cure or 
cause an amelioration of the symptoms of Addison's 
disease. Williams in many instances has found the 
blood pressure raised by the administration of this 
glandular substance by the mouth. 

As the posterior lobe of the pituitary gland has 
been found to furnish a stimulant to the suprarenals, 
it might be well to consider administering a small 
dose of this gland in conditions of subsecretion of the 



ENDOCRINE DISTURBANCE ' 467 

suprarenals, especially as this part of the pituitary 
furnishes a vasopressor substance. 

As yet we have not sufficiently recognized the fact 
that all of the internal secreting glands may be subject 
to the same conditions of hypersecreting and under- 
secreting which are so well recognized as occurring in 
the thyroid gland. It is quite probable that some 
unexplained cases of hypertension are due to an 
increased suprarenal secretion, and it certainly seems 
more than likely that the condition of chronic hypo- 
tension is due to a subsecretion of the suprarenals. 



ACUTE INTOXICATIONS 



DRUG ADDICTIONS 

The Harrison antinarcotic law, which became effec- 
tive March 1, 1915, deprived many addicts of their 
drug and caused considerable suffering. Numerous 
methods have been devised to wean patients from the 
drug habit. 

OBJECTS OF TREATMENT 

1. To stop the drug. 

2. To prevent pain and cause sleep. 

3. To increase all secretions. 

4. To sustain the strength. 

5. To support the heart. 

6. To teach self-control. 

7. To promote nutrition and general health. 
These are the main objects that one must keep in 

mind, and they also represent some of the difficulties 
in the cure of the morphin habit. 

The treatment of an individual addicted to the use 
of opium or morphin should not be attempted unless 
the physician is certain that the patient is absolutely 
under his care and that his directions will be carried 
out in the minutest detail. With a reliable nurse, treat- 
ment may be attempted in a patient's home, but if 
is not often advisable. If a patient is to be treated at 
home, the physician should remember that he may 
become delirious, not only from the withdrawal of the 
morphin, but from any one of the atropin treatments, 
and that he might injure himself, or might jump out 
of a window in order to escape and obtain, if possible, 
what he thinks he needs. Also, the convalescence of 
these patients, like hysteria, is better treated at an 
institution. In fact, it should be stated that generally 
better results are obtained in an institution for the 
treatment of this habit, or in a public or private hospi- 
tal. The physician should exercise the' greatest 
patience, and should show that he has sympathy for his 
patient during his mental and physical trial. At the 
same time the physician should be firm in carrying out 



LAMBERT-TOWNE METHOD 469 

the details of the treatment. He should also in every 
way encourage the patient to exercise his own will- 
power in controlling the symptoms, and later in refrain- 
ing from the use of the drug. 

THE LAMBERT-TOWNE METHOD 

The Lambert (sometimes referred to as the Lambert- 
Towne) method of elimination and rapid withdrawal 
has proved quite satisfactory. While not strictly a cure 
for drug habits, it is intended to obliterate the terrible 
craving which these patients suffer when deprived of 
their accustomed drug. Vigorous elimination is the 
most important feature of the method, and is secured 
by the administration of compound cathartic pills and 
blue mass or some other form of mercury. The other 
essential measure is the persistent use of the following 
belladonna mixture: 

Gm. or C.c. 
IJ Tincturae belladonnae (15 per cent.) 60 

Fluidextracti xanthoxyli 

Fluidextracti hyoscyami aa, 30 

The morphin patient is given five compound cathartic 
pills and 5 grains of blue mass. If these have not 
acted in six hours, he is given a saline cathartic. After 
three or four free movements, he is then given in 
three divided doses at half-hour intervals, two thirds 
or three fourths of his total twenty-four hour mor- 
phin or opium dose. The drug is given in the way 
he usually takes it. After the second dose, Lambert 
cautions the physician to study the patient carefully, 
as a few patients cannot comfortably take more than 
this amount, and should not receive the third dose of 
morphin. Beginning at the same time that the first 
dose of morphin is given, 6 drops, from a medicine 
dropper, of the belladonna, xanthoxylum and hyoscy- 
amus mixture above described are given, and this dose 
is repeated every hour for six hours. At the end of 
six hours the dose is increased by 2 drops. This, bella- 
donna mixture is then continued every hour, day and 
night, continuously throughout the treatment, increas- 
ing 2 drops every six hours until the dose has reached 
16 drops ; this 16-drop dosage is then continued. The 
belladonna drops are diminished, or discontinued, at 



470 LAMBERT-TOWNE METHOD 

any time that the patient shows symptoms of bella- 
donna poisoning, which is evidenced by dilated pupils, 
flushed face, dry throat, or a "peculiar incisive and 
insistent voice and an insistence on one or two ideas." 
If the belladonna treatment has been stopped, it is 
again begun at a reduced dosage as soon as the symp- 
toms have subsided. If there is idiosyncrasy against 
belladonna, it will be shown in the first six or eight 
hours, and the dose must then be diminished. If 16 
drops, the full dose, given for twelve consecutive 
hours does not cause dryness of the throat, the dose 
should be increased to 18, and to 20 drops per hour, 
and when the throat is dry, the dose should be reduced. 

Ten hours after the first dose of morphin, the patient 
is again given five compound cathartic pills and 5 grains 
of blue mass. If they do not act in eight hours, a 
saline cathartic should be given. When the bowels 
have acted thoroughly, one half of the dose of mor- 
phin given at first should be given. As just stated, 
the belladonna drops are still being continued, and ten 
hours after the second dose of morphin has been given, 
that is, about the twenty-eighth hour of the treatment, 
five more compound cathartic pills are given and 5 
grains of blue mass, followed again by a saline if the 
bowels do not act in eight hours. After the bowels 
have thoroughly acted from the last dose of cathartics, 
the third dose of morphin is given, which should be 
one sixth of the first dose. It is stated that usually 
this will be the last dose of morphin required. 

Ten hours after the third dose of morphin, that is, 
at about the forty-sixth hour, five compound cathartic 
pills and 5 grains of blue mass are again given, fol- 
lowed by a saline if needed, and at this time, if not 
before, a bilious green stool should appear. When this 
appears, usually about eighteen hours after the third 
dose of morphin or about the fifty-sixth hour of treat- 
ment, 2 ounces of castor oil are given to clean out the 
intestine. Sometimes, Lambert states, it is necessary 
to continue the belladonna mixture 'over one or two 
more cathartic periods before giving the oil. 

During the last bowel-moving period the patients are 
the most uncomfortable, and their excessive nervous- 
ness and discomfort may be controlled by codein, 



LAMBERT-TOWNE METHOD 471 

which can be given hypodermically in 5-grain doses 
and repeated, if necessary, or some other sedative drug, 
not an opiate, may be utilized. 

At about the thirtieth hour of treatment, the patient 
should be stimulated with strychnin or digitalis, or 
both, every four to six hours. The amount of strych- 
nin is not mentioned; neither is the amount nor the 
preparation of digitalis. Digitalis should rarely be 
given at four-hour intervals. This cardiac stimulation 
is left entirely to the judgment of the physician who is 
caring for the patient. 

It is stated that some patients cannot tolerate the 
codein, as it causes poisoning, and urticarial rash, etc. 
Such patients may receive ethyl-morphin hydrochlorid, 
and Lambert thinks that the latter is twice as strong 
in its activity as codein, and he thinks the dose should 
be "2 or 3 grains, or less." The dosage of this drug, 
according to New and Nonofficial Remedies, is from 
one-quarter to 1 grain. The codein or dionin, which- 
ever is given, should be stopped as soon as possible 
after the castor oil has acted, although it may be given 
during the succeeding twenty-four hours if necessary, 
but it should not be continued more than forty-eight 
hours, as they will acquire this habit, or return to the 
morphin habit. 

Joint and other pains, and bone and muscle aches, 
Lambert says, "can sometimes be relieved by hypoder- 
mics of some form of ergot and strychnin, sometimes 
by massage, sometimes by sodium salicylate, sometimes 
by a salicylic compound combined with some of the 
coal-tar products, such as antipyrin or acetphenetidin ; 
and they can always be eased by codein or dionin. 
The addition of codein to these coal-tar products 
increases their analgesic effect." Of course, it does ; 
and it would seem almost inexcusable, if morphin is 
being withdrawn, to continue codein or ethyl-morphin 
hydrochlorid for more than one or two doses. The 
choice of these drugs is apparently left to the physi- 
cian in charge of the patient. It would seem that the 
more drugs the worse for the patient. All coal-tar 
products are depressant and are dangerous for a heart, 
especially after it has been through the trials that it 
must go through in the two or three days of this treat- 
ment. 



472 PETTEY TREATMENT 

Insomnia, Lambert says, may be treated sometimes 
with bromids, sometimes with chloral or some other 
hypnotic. Veronal, he says, has caused much depres- 
sion. Any of these hypnotics must cause some depres- 
sion. He states that as soon as the patient is up and 
about muscular fatigue caused by regular exercise 
makes him sleep, and usually such exercise can be 
taken at the end of a week. 

CRITICISM 

The drugs used in this treatment might be severely 
criticized. There is probably no necessity for both 
hyoscyamus and belladonna. The xanthoxylum is 
useless. It is probable that any good purgative could 
replace the obsolete compound cathartic pills. 

THE PETTEY TREATMENT 

Dr. George E. Pettey also causes catharsis, and has 
the patient drink large amounts of water to dilute the 
body fluids, and to cause watery movements and a large 
amount of urine. He gives his patient tub and vapor 
baths. His cathartic combination is as follows : 

Gm. or C.c. 

Ifc Calomel I 

Powdered extract of cascara 

sagrada each '| 66 gr. x 

Ipecac |065 gr. i 

Strychnin nitrate 015 gr. V4 

Atropin sulphate J 0013 gr. ^o 

Mix, and make 4 capsules. 



200 



His other medicinal treatment is scopolamin in 1 / 2ts 
grain doses, spartein sulphate in 2-grain doses, and 
during the scopolamin treatment 20 grains of sodium 
thiosulphate every two hours for 24 hours. 

On the first day of the treatment the patient may 
take his usual dose of morphin, but he must go without 
his dinner and supper. Pettey's cathartic prescription, 
which contains atropin and strychnin as above 
described, is divided into four doses and placed in 
capsules. The patient takes one of these capsules 
every two hours, beginning at 4 p. m. The fol- 
lowing morning he receives no nourishment and no 
morphin until his bowels have thoroughly moved. To 



PETTEY TREATMENT 473 

insure that they do move, about 5 a. m. the next morn- 
ing he is given one-twentieth grain of strychnin hypo- 
dermically (although he already has had one-fourth 
grain of strychnin since 4 p. m. the day before). Half 
an hour later he is given two ounces of castor oil or the 
contents of a bottle of magnesium citrate. Both the 
strychnin and the oil or saline should be repeated every 
two hours until the intestinal canal has been thoroughly 
emptied, and no morphin should be given during this 
time. [It would certainly seem as though a morphin 
patient was very tolerant to strychnin, and it may be 
that he is sustained by this large dose of strychnin 
during the first period of going without his morphin'.] 
After the bowels have freely moved, and the craving 
for morpHin becomes insistent, the patient should be 
given from one half to two thirds of his usual dose 
of morphin at the same intervals at which he has been 
accustomed to take the drug. After this free purging 
he may have plenty of food regularly, provided he eats 
nothing for six hours before he begins his second pur- 
gative treatment, which should be at the end of forty- 
eight hours from the first. The cathartic capsule 
should be given in the same way as on the first day. 
The morphin may be continued in reduced dose, just 
sufficient to keep the patient comfortable, until the last 
dose of the cathartic capsule has been given, when it 
is stopped, and no more opiate should be given. From 
six to eight hours after the second purgative course has 
been completed, strychnin hypodermically and the oil 
or saline should be repeated, as before. As soon as the 
patient feels the need of the morphin after this second 
free purging, instead of morphin or an opiate, he is 
given 1 / 200 grain of scopolamin hypodermically, and 
this is repeated in thirty minutes. If the patient does 
not sleep after the second dose, a third may be given in 
half an hour or an hour, which may be of the same 
amount, or double .the amount, depending on the effect. 
This large dosage of scopolamin will cause either sleep 
or a mild intoxication. In either case the patient will 
not suffer. As soon as he wakes, he is given another 
V200 grain of scopolamin, and this atropin intoxication 
should be repeated, if necessary, to keep the patient 
free from pain, for from thirty-six to forty-eight hours 
after it was begun. It should then be stopped. Dur- 



474 PETTEY TREATMENT 

ing the scopolamin period and for twenty-four hours 
afterward, Pettey gives 20-grain doses of sodium thio- 
sulphate every two hours, which he thinks supplements 
the effect of the calomel purgative. 

Convalescence is established on the fifth to the sixth 
day, when medication should cease except treatment 
°imed at improving the general condition of the patient. 
During the treatment a weakened circulation is treated 
by Pettey by giving spartein sulphate in doses of 
2 grains, every four to six hours. 

CRITICISM 

Here, again, the drugs used are susceptible of criti- 
cism. 

Pettey's purgative combination consists of calomel, 
cascara sagrada, ipecac, strychnin and atropin. The 
action of these drugs is sufficiently understood to 
require no further elucidation. Ipecac will increase 
all secretions more or less, perhaps especially the intes- 
tinal secretions. The addition of atropin to the purga- 
tive prescription might be questioned, except that it is 
a fact that every successful treatment seems to require 
something of the atropin series. Also, atropin is known 
to stop the griping of cathartics by dulling the periph- 
eral nerves and preventing intestinal spasm. On the 
other hand, the strychnin will increase normal intes- 
tinal peristalsis, which in morphin takers has become 
more or less decreased. The afore-mentioned cathar- 
tic is aided later by castor oil or magnesium citrate. 
This cathartic treatment emphasizes the fact that 
catharsis is what is needed, and not necessarily any par- 
ticular one or more cathartic drugs. Scopolamin and 
strychnin are added to his treatment. Sodium thio- 
sulphas is largely used externally, rarely internally, 
and has been used as a food preservative. There is no 
doubt that some other drug would serve Pettey's pur- 
pose as well, especially as this drug has not been shown 
to have any special beneficial physiologic activity. 
Spartein is a liquid alkaloid obtained from the broom 
plant, scoparius, and has been used in medicine in the 
form of a crystalline salt, spartein sulphate. It is a 
nervous depressant, and especially a motor paralyzant. 
Earlier experimentation seemed to show that spartein 



JENNING'S TREATMENT 475 

could raise the arterial pressure as well as quicken the 
pulse rate. Clinically, however, it has been found that 
in small doses it has little or no action, and in large 
doses it may cause circulatory depression. It has 
been largely used in irregular or intermittent heart and 
in palpitation, but it has not stood careful clinical or 
hospital tests, and is now very rarely used in cardiac 
depression. 

JENNINGS' TREATMENT 

The treatment of Oscar Jennings consists in giving 
dionin in place of the morphin, accompanied by spar- 
tein sulphate, the doses of dionin being rapidly reduced 
as conditions warrant. Hygienic measures and good 
feeding are also employed with vichy, stimulants, cola 
and other drugs to meet indications. He lays stress on 
the reeducation of the patient in self-control. 

THE METHOD OF SCELETH 

The patient is given a preparatory dose of a saline 
cathartic. The basis of the medical treatment is the 
following : 

Scopolamin hydrobromid gr. M.00 

Pilocarpin hydrobromate gr. M2 

Ethyl-morphin hydrochlorid — dionin)... gr. ss 

Fluidextract cascara sagrada TTj, xv 

Alcohol nx xxxv 

Water qs. ad 3i 

Patients treated by this method are first given a 
saline cathartic, and then the mixture of scopolamin, 
pilocarpin, ethyl-morphin hydrochlodid and cascara 
sagrada in the combination described. The dose varies 
according to the amount of morphin the patient is 
taking. When more than 10 grains of morphin per 
day are being taken, Sceleth gives 60 minims every 
three hours, day and night, for six days. On the 
seventh day the dose is reduced to 30 minims ; on the 
eighth day to 15 minims, and on *the ninth day 15 
minims three times a day, instead of every three hours 
day and night. On the tenth day this treatment is 
stopped, and strychnin nitrate, one-thirtieth grain three 
times a day, is substituted. On the eleventh day the 
strychnin is reduced to one-sixtieth grain three times 



476 SCELETH METHOD 

a day, and this is continued for a week. During the 
first five days he gives a very light diet, but liquids 
freely. 

Patients who are taking less than 10 grains of mor- 
phin a day start with a dose of 30 minims of the mix- 
ture; and if less than 5 grains, 15 minims. 

This treatment represents the substitution of ethyl- 
morphin hydrochlorid for morphin ; the fighting of the 
morphin depression by scopolamin; the necessary pro- 
motion of secretions by pilocarpin, and the necessary 
laxative treatment by cascara. In other words, this 
is apparently the simplest and most rational treatment 
of the three. 

During the first three days of the treatment the 
patients, of course, are sleepless, and they may vomit ; 
but these symptoms occur with any treatment. If the 
pulse goes below 40 or above 120 per minute, the 
scopolamin mixture is stopped, and if there are any 
signs of collapse, one-half grain of ethyl-morphin 
hydroclorid, or one-quarter grain of morphin, is given 
hypodermically. The same is true of any treatment; 
if collapse is in evidence, morphin must almost invari- 
ably be given. 

Sceleth says that in only about 4 per cent, of the 
cases is there scopolamin delirium, and when such a 
condition occurs the scopolamin may be omitted from 
the mixture for a few times and then added in small 
doses. He further says what is very laudable, namely, 
to use no other drugs during the treatment. By the 
fifth day the patient generally has no further desire for 
his morphin and is ready for food, and may have a 
ravenous appetite and gain weight rapidly. 

Sceleth very wisely says that if the cause that devel- 
oped the morphin habit is still present, these patients 
are likely to relapse; if the cause that developed the 
habit has been removed, the patients are generally per- 
manently cured. Consequently, if the cause that devel- 
oped the habit has not been removed, it is a subject 
for the most careful therapeutic and, if necessary, sur- 
gical consideration. There certainly is little use in put- 
ting a patient through the serious ordeal for the cure 
of the morphin habit if recurrent severe pain is sure 
to occur. 



SCELETH METHOD 477 

The physician is urged to study the action of the 
drugs employed in the treatment of the morphin habit, 
and it is recommended that he first try the Sceleth 
method, which would seem to be the least dangerous, to 
cause the least hardship, and probably has as good a 
percentage of cures as any other treatment. 

CRITICISM 

Sceleth combines the laxative cascara sagrada with 
his scopolamin, pilocarpin and ethyl-morphin hydro- 
chlorid treatment. Pilocarpin is an antagonist to 
scopolamin, as it promotes all secretions, especially the 
secretion of the saliva, of the bronchial mucous mem- 
brane, and of the sweat. It also acts against the 
atropin series in causing contraction of the pupils. 
Unlike the atropins, it is never stimulant, is always 
depressant, and the secondary effect is that of pros- 
tration. 

Ethyl-Morphin Hydrochlorid (Dionin) is the hydro- 
chloric! of ethyl ester of morphin, that is, a morphin 
derivative, and the action is more or less closely like 
that of morphin, with a possibility that its secondary 
effects are more depressant. Sceleth in his treatment 
also uses strychnin. 

CONCLUSION 

These three treatments are all atropin treatments, 
with free purging, and the more or less gradual with- 
drawal of the drug, with a subsequent building up of 
the general system and a development in the patient of 
self-control. 

The drugs used in these systems of treatment are 
not here criticized from an unfriendly standpoint, but 
to stimulate, if possible, a more careful study of the 
condition of morphinism in institutions that do not 
blindly follow one orthodox method. There is no halo, 
and there is no zodiacal sign, and there is no one 
prayer, that necessarily accompanies these particular 
combinations of drugs. It is largely the forcefulness 
of the men who carry out the treatment and the per- 
sistency in obtaining the object aimed at through some 
antagonistic drugs, profuse purging, and support of 
the patient through his trial. 



478 LEAD-POISONING 

The final results are, of course, dependent on the 
cause of the addiction. If, since the beginning of the 
habit, the cause has been removed, the patients are 
permanently cured and do not return to the habit. 
Where the cause persists, whether it be functional 
neurosis, a degenerate mentality or criminality, the 
patient occasionally returns to be treated anew. No 
matter what form of treatment is ultimately selected — 
whether slow or rapid withdrawal — individualization of 
the patient is of great importance. The assistance of a 
psychiatrist may be valuable. Above all, institutional 
treatment should be recommended over attempts at 
home care. 

LEAD-POISONING 

In communities in which there are industrial plants 
handling lead, poisoning from this source is frequent. 
It has been shown that the most poisonous or the 
most soluble forms of lead are not necessarily the 
most likely to cause accidental poisoning. Those that 
most readily form dust seem to be most harmful; the 
more the dust is abolished, therefore, in all forms of 
lead factories and lead industries, the less poisoning. 
There is no question, of course, of the danger of lead 
fumes from molten lead. 

In an investigation of this subject Dr. Alice Hamil- 
ton (Jour. A. M. A., 1912, Sept. 7, p. 777) concluded 
that the most poisonous of the lead salts is the suboxid 
which forms on the surface of melted lead, is given off 
in fumes at high temperatures and rubs off on the 
hands of the workers ; this salt causes poisoning in 
smelters, molders, type-setters, plumbers and others. 
The other forms most likely to cause poisoning are lith- 
arge or oxid of lead, and then the higher oxids of lead, 
as red lead, and the carbonate of lead, or white lead. 
Those who clean or scrape off lead paint, and also 
painters, are likely to have poisoning from white lead. 
Lead-poisoning occurs frequently in factories in which 
men work in white lead, and in oxid of lead or red lead, 
and Dr. Hamilton finds that those who work in red 
lead are poisoned sooner than those who work in 
white lead. 



SYMPTOMS OF LEAD-POISONING 479 

She believes that a weak sulphuric acid lemonade, 
which workmen were urged to drink, is not a protec- 
tive against lead-poisoning. It has been proved that 
most forms of lead will be so acted on by the gastric 
juice during digestion that some lead will be absorbed 
The only harmless lead seems to be the sulphid of lead. 

The amount of lead necessary to cause poisoning 
varies greatly, probably according to idiosyncrasy — 
some persons being susceptible, others being tolerant. 
Some artisans, therefore, may work in lead for years 
without evidence of poisoning, while others can work 
but a few weeks before poisoning is apparent. Inves- 
tigations in some of our factories, Dr. Hamilton says, 
showed that from 25 to 35 per cent, of the employees 
had some form of lead-poisoning. Negroes seem 
more susceptible to lead than white men, and women 
are probably more susceptible than men. Fatigue, 
improper housing and insufficient food all render the 
individual more susceptible to lead-poisoning and its 
anemia, as we would logically conclude. Those who 
drink much alcohol are more susceptible to the poison- 
ing, and the tendency to drink beer or whisky in order 
to remove the sickish, disagreeable, sweet taste from 
the mouth, due to the lead salts that are inhaled or 
swallowed, is great with men in these employments. 
Women, on the other hand, drink a good deal of tea, 
or crave sour things, to overcome this disagreeable 
taste. 

It has not been shown that lead is positively absorbed 
from the skin, or that much is absorbed when inhaled 
into the lungs; probably most of the poisoning is 
caused by lead being swallowed into the stomach. 

The diagnosis of chronic lead-poisoning is some- 
times difficult, and for that reason every one should 
be questioned as to his possible exposure to lead, after 
other more tangible causes are excluded, if he loses 
appetite, is pale or anemic, is constipated and suffers 
from indigestion. These are all prodromal symptoms. 
The blue line on the gums may or may not be present. 
If the teeth and mouth are properly cared for the blue 
line is probably not often found. "The basophilic 
granulation of the red cells," which was thought at 
one time to be diagnostic of chronic lead-poisoning, has 



480 LEAD COLIC 

been shown not to be pathognomonic. Although lead 
is usually to be found in the urine of patients who show 
other signs of lead-poisoning, its absence will not 
exclude lead-poisoning. The laboratory test is difficult 
and the specimens should be submitted to experienced 
laboratory workers for report as to lead content. It 
has been suggested, in cases in which the patient is 
working in lead and poisoning is suspected, that a solu- 
ble sulphid be rubbed on the skin, on the theory that 
lead is excreted through the skin, and that if a black 
precipitate is formed it will show that there is lead in 
the tissues. 

Dr. Hamilton concludes that, although one attack of 
acute plumbism is not serious and may leave no dis- 
eased condition, one attack does predispose to another, 
and that probably a man who has had one attack of 
acute colic, for instance, or of wrist-drop, certainly 
should be ordered to stop working in lead, and that the 
employer should refuse him employment. The later 
pathology of chronic lead poisoning becomes that of 
cardiovascular-renal disease on the one hand, or pro- 
gressive anemia, weakened muscles (especially the 
extensors), tremor and emaciation. 

In this anemia nucleated red corpuscles are almost 
always found, even if the anemia is not profound. 

Lead colic may occur suddenly, or after protracted 
constipation, with or without gastro-intestinal pains. 
During the paroxysm the patient generally vomits, the 
pulse is slowed and the blood pressure is generally 
raised. Nothing will stop this kind of pain but large 
doses of morphin, used in combination with atropin. 
Hot fomentations to the abdomen should be used or, 
better, if the patient is able, a hot bath should be taken. 
As soon as the pain is less severe the patient should 
receive a saline cathartic, and best perhaps Rochelle 
salt, as, in spite of the unusual innocuousness of mag- 
nesium sulphate, it should not be forgotten that, occa- 
sionally, if magnesium sulphate does not cause purg- 
ing and is absorbed, it can cause nervous depression 
not dissimilar to that which may occur from lead. 

The after-treatment of lead-poisoning of this nature, 
or if chronic lead-poisoning is diagnosed without lead 
colic occurring, is a daily morning dose of Rochelle 



DELIRIUM TREMENS 481 

salt or something similar and the administration of 
small doses of sodium iodid. The dose of iodid should, 
as a rule, be small, not more than 0.20 gm. (3 grains) 
three times a day, after meals, as large doses may cause 
more lead in the system to become soluble than is 
desired, and more acute symptoms of lead-poisoning 
to occur. Anything that builds up the nutrition is 
also good after-treatment for chronic lead-poisoning; 
for example, the administration of small doses of iron, 
and the prevention of high blood pressure and a possi- 
ble beginning cardiovascular-renal disease. 

If lead palsy, which in its most frequent form is 
wrist-drop, is present, the tonic treatment mentioned 
before should be carried out with the addition of 
strychnin and the use of electricity and massage. 

Acute cerebral symptoms not infrequently occur. 
These symptoms may be delirium, epileptiform con- 
vulsions, or more or less coma. Occasionally hallucina- 
tions and insanity are caused by the action of lead on 
the brain. These conditions are all exceedingly serious. 
While wrist-drop is generally curable, more profound 
paralysis of the arms and legs is much more serious. 

Prevention, of course, should be considered by every 
employer and should be understood by every employee 
who has anything to do with industries that make or 
handle lead. A patient who has once been poisoned 
by lead should either leave his occupation or should 
inaugurate such means of prevention of future poison- 
ing as are efficient. Personal cleanliness is one of the 
greatest factors in the prevention of lead-poisoning. 

DELIRIUM TREMENS 

In individuals who have habitually used considerable 
quantities of alcoholic stimulants, even although they 
may rarely, perhaps never, drink to intoxication, the 
unfavorable effects of the chronic indulgence in alcohol 
are frequently seen when acute or chronic illness super- 
venes. Especially in the severe acute infections, like 
pneumonia, the symptoms are frequently modified or 
added to by the effects of the habitual use of alcohol. 
Alcoholism may imitate many disturbances of the ner- 
vous system and it may require the highest acumen of 
the physician to make a correct diagnosis. 



482 SEDATIVES IN DELIRIUM TREMENS 

A common characteristic of these cases is the loss of 
appetite, accompanied often by nausea and vomiting, 
so that it is difficult for the patient to retain either 
nourishment or medicine. If the stomach is irritable, 
it is necessary to give such gastric sedatives as bis- 
muth or bicarbonate of sodium, with such aromatics 
as capsicum or peppermint. The stomach being in a 
condition to retain food, abundance of light nourish- 
ment should be administered at regular intervals. 

SEDATIVES 

At the first appearance of restlessness and insomnia 
the patient should be given the bromid of sodium in 
1-gm. (15-grain) doses, repeated every two, three, or 
four hours. In the evening, when it is natural to desire 
that the patient should sleep, a more active hypnotic 
should be used. Chloral in a dose of 1 gm. (15 
grains), and repeated in one hour if needed, will gen- 
erally prove effective in securing prolonged sleep, after 
which the patient's condition will frequently be found 
very much improved. 

Although chloral is undoubtedly the peer of all hyp- 
notic drugs, it is rated as a cardiac and circulatory 
depressant, and, as is well known, can cause heart 
failure and death. All hypnotics except morphin, how- 
ever, in sufficient doses to produce sleep, are cardiac 
depressants, and it is quite probable that a dose of 
chloral which is sufficient to produce sleep in a patient 
with delirium tremens is no more depressant than the 
dose of other hypnotics sufficient to produce sleep in a 
patient in the same condition. If the circulation is 
notably weak, however, other hypnotics may be 
selected. Paraldehyd has had a long period of 
approval. Its action is rapid, and many times satis- 
factory. If the dose is sufficient, there may be con- 
siderable circulatory depression for a short time. The 
various synthetic hypnotics, old and new, sulphonme- 
thane (sulphonal), sulphonethylmethane (trional), 
diethyl barbituric acid (veronal), and sodium diethyl- 
barbiturate (veronal-sodium), all act more or less sat- 
isfactorily, but act much more slowly than do chloral 
or paraldehyd and, in doses that are sufficient, will 
produce considerable later depression. A sufficient 






TREATMENT OF ACTIVE DELIRIUM 483 

dose of scopolamin hydrobromid, hypodermatically, 
to cause sleep in this excited condition, is likely to 
cause depression. Also, there often is an increased 
susceptibility to any atropin or atropin-containing drug, 
so that the cerebral excitement may be increased by 
scopolamin. 

In cases of acute illness in which, on account of the 
history of alcoholic addiction, there is reason to believe 
that symptoms referable to the habitual use of alcohol 
are liable to supervene, the use of sedatives should be 
commenced early, before any of the characteristic 
symptoms of alcoholism appear, and should be con- 
tinued until it is evident that there is no danger of 
prolonged insomnia and restlessness. 

In severe cases in which active delirium with hallu- 
cinations has supervened, energetic treatment is 
urgently demanded. Danger must be looked for in 
two or three directions. The circulation is threat- 
ened, owing to the weak action of the heart, which 
may result in edema of the lungs. At the same time 
the circulation in the brain is especially affected so 
that there is a passive congestion, with more or less 
edema. Added to this are the symptoms of exhaustion 
due to the insomnia and violent muscular agitation. 
Here there is urgent necessity of maintaining the 
nutrition of the patient by giving liquid nourishment 
at regular intervals. It is necessary also to watch the 
circulation carefully and to maintain the action of the 
heart. The use of alcoholic stimulants for this pur- 
pose, while still recommended by many, is of doubtful 
propriety at this stage of the disease. 

If there is serious cerebral excitement and hyp- 
notics in ordinary doses do not act, a good treatment 
is ergot, in some reliable aseptic form, injected intra- 
muscularly into the deltoid muscle, a syringeful at a 
dose. One hour after this injection, a hypodermic 
injection of morphin may be given, not more than *4 
of a grain. 

Theoretically morphin is not good treatment when 
there is cerebral excitement, as the dose required to 
quiet such excitement is very large, while smaller 
doses tend to increase the excitement. Under the 
condition described, however, ergot given first to 



484 LUMBAR PUNCTURE IN DELIRIUM TREMENS 

relieve congestion of the brain and spinal cord and 
followed by morphin, prevents the initial excitement 
of the morphin and projectes the length of time which 
a given dose of morphin will act, and the outcome is 
satisfactory. 

LUMBAR PUNCTURE 

The belief is becoming more or less general that one 
of the important factors in delirium is increased pres- 
sure in the cerebrospinal fluid and lumbar puncture 
will relieve this. Schottmuller and Schumm found a 
marked elevation in the pressure of this fluid in 80 
per cent, of the cases of acute alcoholism examined 
by them, and in one instance they drew as much as 
100 c.c. with no unfavorable reaction. Steinebach 
found a similar condition in 75 per cent, of patients 
with alcoholic delirium, and in the remainder there 
was a relative increase in the pressure of the fluid. 
That this increased pressure may be responsible for 
the delirium, and is not merely a condition which 
accompanies chronic alcoholism, is indicated by the 
fact that increased pressure is not found in alco- 
holics before or after an attack of delirium 
tremens, nor do habitual drinkers who are not suf- 
fering from acute alcoholism or who v have not had 
delirium show an increased pressure. Further, if 
delirium tremens is due to increased pressure, the 
lowering of the tension by lumbar puncture should 
cause an improvement in the patient's condition. In 
this regard Steinebach's results are to the point. In 
every case the delirium grew milder; frequently it 
ended entirely. The disorientation as to time and place 
usually remained for a while. In two instances the 
delirium returned. Following a second puncture, an 
increase in the pressure was again found and the 
delirium soon abated. In the total series of eighteen 
cases, the average duration of muscular unrest follow- 
ing lumbar puncture was from three to four hours, 
and of delirium twenty-four hours. In thirty-three 
cases in which lumbar puncture was not done, the 
average of the restless days was four, and of the 
delirium, five days. Thus, through lumbar puncture 
the duration of delirium was shortened 60 per cent, 
and the restlessness 75 per cent. This series of cases 



CEREBRAL EDEMA 485 

was punctured during the first twenty-four hours of 
delirium. Of the cases that were punctured on the 
second day following the onset of the delirium, 
improvement occurred less rapidly. Here the average 
duration of restlessness was from six to seven hours, of 
mental confusion twenty-four hours, and of delirium, 
eighty hours. 

The manner of action of lumbar puncture in delirium 
tremens has been thought to be the same as that 
described by Quincke for puncture in acute serous 
meningitis. If the intraventricular pressure reaches 
a certain point, the usual channels of escape for the 
spinal fluid become occluded. Then, by lumbar punc- 
ture, the hypertension is released and healing begins. 
Certain facts, however, make another explanation nec- 
essary. First, lumbar puncture works equally well in 
cases which show only a relative increase in pressure ; 
second, Steinebach found that after the withdrawal of 
the spinal fluid in these cases, the reinjection of from 
15 to 20 c.c. of physiologic salt solution gave even 
more beneficial results. These facts indicate that 
there is probably some toxic irritant present in the 
spinal fluid. Accepting this view, the best treatment 
of delirium tremens is a spinal puncture which releases 
the pressure and removes part of the toxic substance 
and a dilution of what remains by the injection of 
salt solution. 

CEREBRAL EDEMA 

If there are signs of cerebral edema, no treatment is 
better than, or so satisfactory as, the subcutaneous 
ergot treatment. The ergot may be repeated in three 
hours, and then once in six hours for several doses, 
if it is required. The administration of ergot by the 
mouth for the action desired on the brain is absolutely 
unsatisfactory and cannot be relied on. Also, if the 
heart is weak ergot is the drug indicated. 

In other words, if there is apparent edema of the 
brain, ergot; if there is cerebral excitement and the 
heart is efficient, chloral ; if there is cerebral excite- 
ment and the chloral is unsatisfactory alone, add ergot; 
if there is cerebral excitement and the heart is weak, 
ergot and morphin. 



486 HOGAN'S TREATMENT 

Strychnin is ina'dvisable as a stimulant in this con- 
dition. A saturated solution of camphor in an aseptic 
oil may be given hypodermatically, if required, as a 
quickly acting stimulant. Strophanthin hypodermati- 
cally may be given, if deemed advisable. Digitalis, 
which does not act well for at least twenty hours, is 
generally not indicated. 

In the meantime, while these various dietetic and 
medicinal measures are being employed, the patient 
should be kept quiet, should be constantly watched, 
and should be frequently bathed with warm water, or, 
if strong enough, given hot baths. 

hogan's treatment 

Hogan (Jour. A. M. A., Dec. 16, 1916, p. 1826) 
describes the treatment used by him in cases of severe 
alcoholic delirium, in all of which he has observed a 
severe acid intoxication, and the effect of the toxins on 
the nervous system and liver may show anything from 
simple edema to severe degenerative changes of fhe 
fatty type. Any treatment to be of service must be 
used in the stages of edema, and after experimenting 
with various salts capable of dehydrating edematous 
tissues, he has devised a mixture of sodium bromid, 
sodium chlorid and sodium bicarbonate which can be 
used in large quantities intravenously, without produc- 
ing the toxic effect of bromid as ordinarily given in 
large doses. As the severe types also suffer from a 
starvation acidosis, glucose in highest concentration is 
also used intravenously. This not only furnishes an 
available carbohydrate, readily utilized by the body, 
but in 30 per cent, concentration produces marked 
dehydrating effects on the central nervous systems. 
Sixty-four patients were treated. The mortality was 
9.3 per cent., and the average time of detention 2.63 
days. The after-treatment followed in all cases con- 
sisted of active elimination produced by 0.3 gm. calo- 
mel followed by 30 gm. magnesium sulphate. The 
diet followed the general hospital routine. In his 
private practice he feeds the patient sugar in large 
quantities and furnishes alkali to keep down the acid 
intoxication. "In preparing the solutions 5.8 gm. of 
chemically pure sodium chlorid and 8.4 gm. of chem- 






METHYL ALCOHOL POISONING 487 

ically pure sodium bicarbonate are boiled in 120 c.c. 
of distilled water and filtered through paper, then 
placed in a flask and reboiled. In addition 10.2 gm. 
of chemically pure sodium bromid is boiled in 30 c.c. 
distilled water, filtered and reboiled. These may be 
kept ready for use and, when needed, added to 850 c.c. 
of either freshly distilled water or tap water that 
has been filtered and boiled. Under no circumstances 
should old distilled water be used, as I have found that 
it produces severe chills. This mixture is heated to 
about 110 F. and is ready for use. The glucose used 
in the early cases was the anhydrous variety, but on 
account of the price and our inability to procure it in 
sufficient quantity; I found that I could prepare the 
glucose crystals found in the market and the results 
were satisfactory. In a flask with 250 c.c. distilled 
water 80 gm. are placed and boiled. To this is added 
0.25 gm. of charcoal. This is allowed to stand for 
twenty-four hours, is then filtered into a clean flask, 
reboiled and is ready for use. This solution may be 
made and kept ready for use. Both of these solutions 
must be given very slowly, from twenty to thirty min- 
utes being taken for the 1,250 c.c. A small percolator, 
such as is used in giving salvarsan, with rubber tubing 
and needle attached, is all the apparatus that is needed." 

METHYL, WOOD, ALCOHOL POISONING 

The Volstead prohibition act, which caused the 
obtaining of alcohol for beverage purposes to become 
an exceedingly difficult procedure, undoubtedly led 
some persons addicted to alcohol to attempt the use of 
substitutes. Among those most frequently used was 
the dangerous methyl or wood alcohol. This substance 
has long been used in the industries and has been a 
prolific cause of severe and frequently fatal types of 
poisoning. 

SYMPTOMS 

Among the first symptoms to appear usually are 
nausea and weakness. There may be associated pain 
in the back, headache, marked thirst and difficult res- 
piration. Another early symptom is the dimness of 
vision, which proceeds into the well-known wood- 



488 METHYL ALCOHOL POISONING 

alcohol blindness. The patients appear cyanotic. The 
temperature is variable. There may be headache and 
vertigo, tinnitus aurium, and in severe cases delirium 
with hallucinations. Ophthalmoscopically there is cen- 
tral scotoma with subsequent findings of optic atrophy. 
Harrop and Benedict (Jour. A. M. A. 74: 25, 1920) 
found no disturbance of phenolsulphonephthalein 
excretion or of the normal blood urea concentration, 
but they did find acidosis of a severe grade to be a 
prominent factor in the symptomatology. The bicar- 
bonate content of the blood plasma as determined by 
the Van Slyke method was as low as 36.0 per cent, by 
volume equivalent to carbon dioxid. 

The foremost reason for the unlike physiologic 
behavior of the two commonest alcohols lies in the 
unlike readiness with which they are oxidized in the 
body. Ethyl alcohol may be excreted to a small degree 
through the eliminatory organs ; but for the most part 
it is burned up much as are the ordinary foodstuffs. 
Hence the contention that alcohol may be a food. 
Methyl alcohol, on the other hand, is oxidized with 
difficulty. More than half of a nontoxic dose may 
find its way out of the body again through the respira- 
tory channels. Furthermore, the progress of the elim- 
ination of the unoxidized portions is comparatively 
slow, so that the output from a single dose may even 
continue during an entire week. As a consequence of 
these features — deficient oxidation and slow elimina- 
tion — the poison delays in the organism unduly long 
to continue its detrimental effects. 

The fact that a portion of the nervous system — the 
optic nerve — is especially affected by methyl alcohol 
naturally suggests that this substance has a preferen- 
tial affinity for the nervous tissue. Recent researches 
of Pohl (Arch. f. Exper. Path. u. Pharmakol. 83: 204, 
1918) at the Pharmacologic Institute of the University 
of Breslau indicate that this suspicion is not verified. 
It almost seems, says Pohl, as if no organ retains so 
little methyl alcohol as does the brain. We must there- 
fore assume that the nervous system is peculiarly sen- 
sitive to the toxic agent rather than that it is unduly 
overwhelmed by larger quantities concentrating in this 
tissue. 



NITROBENZINE POISONING 489 

TREATMENT 

The prospect of effective treatment in the case of 
an agent exhibiting this peculiar behavior is not par- 
ticularly promising. Pohl found in the case of anmals 
poisoned with wood alcohol that a combination of 
bloodletting and injection of Ringer's solution seemed 
to decrease the concentration of the poison in vitally 
affected tissues. A similar result followed the intro- 
duction of charcoal subcutaneously into the body, this 
substance apparently serving to> remove part of the 
unexcreted alcohol by specifically adsorbing it. Such 
procedures, interesting as they are in pointing the way 
to the possibilities of treatment, are far from prac- 
ticable in the exigencies of human cases. 

Based on these studies and on the laboratory findings 
in cases of wood alcohol poisoning, Harrop and Bene- 
dict mention as the two main features of the treatment : 
gastric lavage during the first three days and correction 
of the acidosis by intravenous injection of sodium 
bicarbonate. From 400 c.c. to 500 c.c. of a 5 per cent, 
solution of sodium bicarbonate may be given intra- 
venously and repeated on succeeding days as the condi- 
tion of the patient, indicated by the laboratory findings, 
warrants. Since the methyl alcohol is excreted into 
the stomach for several days following the appearance 
of the first symptoms repeated gastric lavage aids in 
removing some of the poison from the body. The 
patient should of course be given symptomatic treat- 
ment for the relief of pain and delirium and the eyes 
should have attention by a competent ophthalmologist. 

NITROBENZENE POISONING 

This substance, used in the dye industry, in shoe 
polish, soaps, etc., has also been employed for denatur- 
ing alcohol. Many cases have been reported in which 
persons who had recently worn freshly dyed shoes 
developed cyanosis, vertigo, headache and tinnitus. 
The chief symptoms as observed by Stifel, Scott and 
Hanzlik, and Sanders (Jour. A. M. A. 72: 395, 1919; 
74: 1000, 1920; 74: 1518, 1920) were caused by the 
methemoglobinemia. This is manifested by a grayish- 
blue cyanotic color of the skin and visible mucous 



490 ILLUMINATING GAS POISONING 

membranes, often with nausea, vomiting, great muscu- 
lar weakness, marked dyspnea, delirium and convulsive 
movements. Total unconsciousness and coma may 
supervene followed by death from respiratory par- 
alysis. The condition is not usually fatal. Of some 
thirty-six cases recently reported there was but one 
death, that of a man who drank shoe polish, as reported 
by Donovan (Jour. A. M. A. 74: 1647, 1920). The 
treatment should be symptomatic and supportive. 

ILLUMINATING GAS POISONING 

Through the introduction of various forms of gas 
heaters and special illuminating devices this form of 
poisoning is becoming more frequent. Suicide by this 
method is also increasing because of its facility. 

Persons poisoned with illuminating gas should 
receive at once as much fresh air as possible; the 
tongue should be drawn forward and if respira- 
tion is failing artificial respiration should be begun. 
The use of various devices has been advocated in 
such cases, and a report on them has been issued 
by a committee appointed by the American Medi- 
cal Association and the United States Bureau of 
Mines. In selecting such a device the possibilities 
of the machine for harm should be considered. The 
machine should be investigated as to its capabilities 
of producing suction, too great inflation, or other 
injury. Ordinarily the most simple devices or simple 
methods, like the Sylvester method, will serve. 
Venesection may be done from one arm, and from 
"a pint to a pint and a half of blood should be 
removed," and simultaneously a quart of physiologic 
saline solution should be transferred into the median 
basilic or cephalic vein of the opposite arm. Two 
hours later, if there is not sufficient improvement, 
venesection may be done again. Saline solutions should 
be given subcutaneously every two hours in quantities 
of one pint; or, perhaps better, the saline should be 
given by the colon by the continuous method. 

For stimulation, hypodermic injections of strychnin 
or camphor in oil may be given ; strophanthin may be 
given ; strong coffee may be given by the mouth, if the 
patient is not totally unconscious. Physiologic saline 



... 



ILLUMINATING GAS POISONING 491 

solutions may be injected into the rectum by the drip 
method, or from 300 to 500 c.c. may be given every 
three hours subcutaneously under the breast. Other 
substances that can be tried are hypodermic injections 
of 2 c.c. of ether, % 00 grain of atropin, or 2 minims of 
epinephrin solution (1:1,000). The body, especially 
the feet, should be kept warm. 

Yandell Henderson (Jour. A. M. A., Aug. 19, 1916) 
calls attention to the fact that the poisonous effect of 
the gas is entirely due to its avidity for hemoglobin, 
with which it forms the same kind of combina- 
tion as does oxygen, but 250 times as strong. Its 
poisonous effects seem to be wholly due to the 
resulting decrease in the oxygen-carrying power of 
the blood. It is misapprehension, however, to sup- 
pose that the compound is permanent or induces any 
lasting deterioration of the oxygen-carrying power. 
The combination of the carbon monoxid immediately 
begins to break up when oxygen can be introduced or 
the sufferer is carried into the fresh air, if this is done 
within fifteen or twenty minutes or half an hour. 
Very often, however, the victim never recovers con- 
sciousness and dies a day or two later. Use of bleeding 
and transfusion is seldom effective and the patient, if 
he recovers, does so in spite of them. Left to itself, 
nature does all as far as we now know to stop the 
sequels of the poison. As a rough estimate, it may be 
stated that usually a man will die who has breathed 
0.2 per cent, of carbon monoxid in normal air for four 
or five hours, when with from 2 to 5 per cent carbon 
monoxid, as in coal dust explosion, nearly all the hemo- 
globin is combined in the first few breaths drawn and 
death occurs almost as quickly as in drowning. About 
all that can be done in case of poisoning is to administer 
artificial respiration when that of the patient has 
failed, to administer oxygen for half an hour, to keep 
the patients warm if their temperature has fallen, to 
supply water to the system, preferably by a Murphy 
drip, and otherwise give them good nursing and such 
symptomatic treatment as seems advisable. Hender- 
son adds to these rather negative suggestions one of 
an experimental character, owing to the resemblance 
of the coma to that of diabetes indicating an intense 



492 HEAT PROSTRATION 

acidosis. Accordingly, in two cases he administered 
a 3 per cent, solution of sodium bicarbonate intra- 
venously, in one case the total of two quarts given at 
intervals in two hours and in the other 4 quarts in 
six. His conclusions are as follows: "1. Carbon 
monoxid does not form a permanent compound with 
hemoglobin. Its toxic effects are wholly due to 
the inability of the blood combined with carbon 
monoxid to transport oxygen to the tissues. 2. 
In the presence of excess oxygen, or even of 
pure air, carbon monoxid is rapidly given off and 
the oxygen-carrying power of the hemoglobin is 
restored. 3. The continuance of coma, the subsequent 
tissue degeneration and death after several days, 
resulting from carbon monoxid poisoning, are not due 
to retention of the gas, but are the results of injury to 
the brain and other organs by the insufficiency of 
oxygen supplied to them by the blood while the patient 
was breathing the gas. 4. There is no reason to 
believe that either bleeding or transfusion of blood 
are beneficial. They are more likely to be harmful. 5. 
Fresh air — with oxygen inhalation for a short time as 
early as possible — symptomatic treatment, and good 
nursing are the only measures to be recommended. 
Practically the die is already cast for death, permanent 
defects, or complete recovery at the moment when the 
patient is brought out of the asphyxial atmosphere. 
6. It is just possible, theoretically, that alkali therapy 
may be beneficial in combating the acidosis induced 
by asphyxia." 

If the patient survives, the urine should be watched 
daily for some time, that disturbances of the kidneys 
may be immediately noted. 

In all serious conditions of shock, coma and collapse, 
while everything that ought to be done should be done, 
there is a constant tendency to do too much, especially 
with drugs hypodermatically. 

HEAT PROSTRATION AND SUNSTROKE 

It is customary to divide the cases of illness due 
to excessive exposure to high temperature into two 
classes : one is distinguished as heat exhaustion ; the 
other as sunstroke, or thermic or heat fever. It is 



TREATMENT OF HEAT EXHAUSTION 493 

important to recognize the distinction between these 
two classes of cases, as their treatment is entirely 
different. 

Heat exhaustion is considered by many as a milder 
affection, although it frequently results in death. It 
may occur in those who are not exposed to the direct 
rays of the sun, but who are engaged in occupations 
which are accompanied by unusual heat, such as 
bakers, laundrymen, and foundrymen. It is associated 
with vasomoter paralysis. The beginning symptoms 
usually are dizziness, slight headache and throbbing 
in the head, nausea, and sometimes diarrhea; these 
symptoms increasing, _ the patient becomes cold, the 
skin becomes pale and clammy, great prostration 
ensues, the patient is restless, and may become uncon- 
scious. The temperature is usually subnormal, and is 
never elevated. The pulse is weak. 

TREATMENT OF HEAT EXHAUSTION 

The treatment of this condition embraces removal 
of the patient from the influence of the excessive heat 
to which he has been subjected. If he has been out 
of doors in the sun, he should be immediately removed 
to the shade, and as quickly as practicable be taken 
into a house or a hospital. He should be placed 
in bed in a room which is cool and well ventilated. 
The clothing should be loosened so as not to interfere 
with respiration or circulation, his working clothes 
should be removed, and hot applications should be 
placed around his extremities so as to restore the circu- 
lation and make him warm. If he is unconscious, so 
that he cannot swallow, inhalations of ammonia should 
be given by the nostrils. A mustard paste should be 
applied to the back of the neck and over the spine; and 
if the respiration is obviously impaired, a hypodermatic 
injection of 1/100 of a grain of sulphate of atropin 
should be administered. If the heart is weak, a hypo- 
dermatic injection of 1/30 of a grain of strychnin 
sulphate should be given. As soon as the patient is 
able to swallow, he may be given hot coffee and spirits 
of camphor, or a hypodermic of caffein. If the circula- 
tion is improved, the body becomes warm, and the 
patient regains consciousness. 



494 TREATMENT OF SUNSTROKE 

In the second class of cases which are termed sun- 
stroke or heat fever, the patient will be found in an 
entirely different condition. Usually on the arrival of 
the physician the patient will be found to be exceed- 
ingly hot, with a dry skin, a congested face, with 
veins swollen and arteries throbbing. The patient's 
temperature will usually be found elevated to from 
105 to 110 degrees, or even higher. There is great 
restlessness ; the breathing may be stertorous ; the pulse 
is full and rapid; the pupils, dilated at first, may 
become contracted, and unconsciousness may rapidly 
supervene. These symptoms may have come on with- 
out very much premonitory warning. They require 
prompt and active treatment. 

TREATMENT OF SUNSTROKE 

The patient must at once be removed to the shade, 
and as soon as practicable to a cool and welWentilated 
room. His clothing having been removed, and his 
temperature having been taken, he should, if prac- 
ticable, be at once placed in a tub of water at a tem- 
perature of 80 F., to which ice should be gradually 
added. At the same time, ice should be applied to the 
head. While the patient is in the ice-bath, he should 
be rubbed vigorously to promote the peripheral cir- 
culation and bring the hot blood to the surface of the 
body where it may be cooled. The temperature should 
be taken in the rectum every fifteen minutes, and as 
soon as it has fallen to 102 the patient should be 
removed from the bath; otherwise the temperature 
may continue to fall until it becomes subnormal, and 
the patient may pass into a condition of collapse. 
Ordinarily this bath should not be continued longer 
than from twenty to forty minutes, but it may be 
repeated after an interval of two, three or four hours 
if the temperature should again become elevated. In 
some of these cases in which it is obvious that a con- 
gestion of the internal viscera is embarrassing the 
action of the heart, venesection may be performed, 
and a pint of blood may be removed. This loss of 
liquid from the circulation may subsequently be 
restored by the injection of physiologic saline solu- 
tion, if it is deemed advisable. 



TREATMENT OF SUNSTROKE 495 

If there seems to be a tendency to edema and 
congestion of the lungs, a hypodermic injection of 
1/100 of a grain of atropin sulphate should be admin- 
istered. 

If, after the temperature has commenced to fall, 
the pulse becomes weak, a hypodermic injection 
of 1/30 of a grain of strychnin sulphate may be 
administered. 

If the elevation of the temperature is not so great, 
or if the use of the bath is impracticable, the patient 
may be laid on a cot, over which a rubber blanket 
has been placed, and a sheet rung out of cold water 
may be wrapped about him. He may then be rubbed 
with ice. After the sheet has become warm it may 
be removed and another one which has been allowed 
to soak in cold water may be substituted for the first. 

Woolley {New York Med. Jour., 1914, 99, p. 1165) 
believes that to replace the water lost to the body 
before the attack, and to increase elimination, there 
is no better method than infusion of saline solutions. 
If it is true that the oxygen content of the body is low 
and the acid content high, then such alkaline solu- 
tions as those recommended by Fischer are extremely 
efficacious, whether given by rectum or intravenously, 
in neutralizing the acids of the body and increasing 
water elimination by the kidneys. The solution for 
rectal use he urges should be prepared as follows : 

Sodium chlorid 30 gm. 

Sodium carbonate (crystallized) ... 20 gm. 

Water 1,000 c.c. 

The injection should be given slowly enough to allow 
retention. The time consumed in injecting a liter 
should not be less than one hour. 

For intravenous injection the following solution may 
be used: 

Sodium chlorid 14 gm. 

Sodium carbonate (crystallized) 10 gm. 

Water 1,000 c.c. 

This also should be given slowly. 
The effect of these solutions on the secretion of 
urine, Woolley states, is remarkable. 



496 EFFECT OF SUNSTROKE 

AFTER EFFECTS 

Persons who have been the victims either of hea 
exhaustion or of heat fever often suffer more or less 
from the effects of heat during the remainder of their 
lives. It is always wise to warn patients or their 
friends of this possibility, and to direct them to avoid, 
as far as possible, exposure to the direct rays of the 
sun or to overheated rooms during the summer. They 
should be advised to practice cold bathing and, 
if possible, sea bathing during the summer months. 
Sometimes the administration of tonics, and especially 
quinin sulphate combined with strychnin sulphate or 
extract of nux vomica, has seemed to aid these per- 
sons in withstanding the effect of the summer heat. 
Persons who seem to be predisposed to be affected by 
the heat should avoid exposing themselves as much 
as possible; they should dress lightly, should drink 
plenty of water, should avoid indulgence in alcoholic 
drinks, should keep their heads as cool as possible. 
These precautions may wisely be observed by everyone 
in hot weather, and especially when an excess of 
humidity in the atmosphere diminishes the perspiration 
of those who are working, or are exposed to very 
hot air. 

Some patients who have suffered severe sunstroke 
find that their memory is greatly impaired afterward, 
and that they never have the same mental ability and 
memory. Little can be done to benefit this condition, 
but if one feels that he should give the patient some- 
thing in the hope that it may do some good, probably 
nothing will be more likely to prove beneficial than 
the glycerophosphate of calcium or some form of 
phosphorous. 

Not infrequently infants and young children suffer 
from the effects of extreme heat. This condition 
should be looked for in children who are suddenly 
taken ill in the hot weather without any apparent 
reason. If they are found suffering from a high tem- 
perature for which no other explanation can be found, 
and if the history of the case shows that they have 
been exposed to high temperature, they should be 
placed under favorable conditions in a cool, airy 
room, and given a sponge bath of cool water, and cold 



ASPHYXIA 497 

drinks should be administered. If the heart becomes 
weak, tea or coffee, well diluted, may be administered. 
Sometimes after exposure to excessive heat there 
is twitching in the muscles, and even severe convul- 
sions. When the convulsions occur and continue they 
may be controlled by a hypodermic injection of % 
grain of morphin with 1/150 grain of atropin. If 
they resist this treatment, the patient may be anes- 
thetized by the administration of chloroform, or a 
rectal enema containing 2 gm. (30 grains) of bromid 
of sodium and 1 gm. (15 grains) of hydrated chloral 
may be administered and repeated, if necessary, after 
one hour. It may be of advantage to do spinal punc- 
ture. 

ASPHYXIA 

ASPHYXIA FROM SUBMERSION I DROWNING 

Most individuals who become asphyxiated from sub- 
mersion in water or from drowning are dead when they 
are taken out of the water, and all efforts to restore 
them to life are futile. This is especially the case if 
complete submersion has lasted four or five minutes. 
The occasional instance of the successful treatment of 
this form of asphyxia, however, makes it incumbent 
on the physician to be thoroughly informed as to the 
best methods to employ in the treatment of these cases, 
and to be prepared to carry them out if he happens to 
be near when the patient is taken out of the water. 

In the first place, the water must be expelled, so far 
as possible, from the respiratory passages. Probably 
there is no better way of doing this than by inverting 
the patient by taking hold of his feet and raising them 
up and letting his head hang down. This is a simple 
maneuver, provided the bystanders have strength 
enough to carry it out. Rolling the patient on a barrel 
is a crude and harsh substitute. Having removed the 
water as far as possible from the chest, the next thing 
to do is to perform artificial respiration. There are 
a number of methods of doing this. 

The socalled method of Marshall Hall was first 
described in 1858, and consists in rolling the patient 
alternately from the lateral to the prone position and 
pressing the back between the shoulder blades when 
he is in the latter position. This has the advantage that 



498 RESUSCITATION 

the tongue does not fall back into the throat and so 
obstruct the larynx, and the water and mucus readily 
flow out of the mouth. 

The following year the socalled Sylvester method 
was described. This consists in allowing the patient to 
lie on his back with his shoulders raised and his head 
hanging low. The operator then takes hold of the 
arms of the patient above the elbows and draws them 
gently away from his body until they arrive at a point 
above his head. This raises the ribs and increases the 
capacity of the chest. The arms then are carried down 
by the side and the elbows flexed and pressed against 
the lower part of the chest, thus diminishing the 
capacity of the chest and driving the air out. In this 
method the tongue is likely to fall back into the throat 
and interfere with respiration unless some one grasps 
it and pulls it forward. 

In 1868, Dr. B. Howard of New York described a 
method of treating these cases which consists in lay- 
ing the patient on his back while the physician kneels 
over the lower part of the body and presses on the 
lower part of the chest so as to diminish its capacity. 
He then relaxes the pressure, and the natural elas- 
ticity of the chest increases the air capacity. In this 
method also the tongue is liable to fall backward, and 
must be drawn forward. It is objected that in elderly 
patients the ribs are brittle and may be fractured, and 
that the liver is congested and may be ruptured. 

Finally it remains to describe the method known as 
that of Professor E. A. Schafer, professor of physi- 
ology in the University of Edinburgh. He recom- 
mends that the patient be placed in the prone position. 
The physician being astride the patient, the open hands 
are placed on either side of the lower ribs and firm, 
but not violent pressure is exerted. This may be done 
by allowing the weight of the body to come on the 
arms. After this pressure has been exerted for three 
seconds the body may be brought upward and the pres- 
sure relaxed. This should be repeated at intervals of 
five seconds, or twelve times in a minute. 

Schafer made investigations with a view to compar- 
ing the utility of the various methods of artificial res- 
piration. He found that in natural respiration the air 



SCHAFER METHOD OF RESUSCITATION 499 

exchanged in a minute by a person breathing thirteen 
times a minute was 5,850 c.c. The amount of tidal air 
at each breath, therefore, would be 450 c.c. Employing 
the Sylvester method, the amount of air exchanged in 
a minute was 2,280 c.c, showing the tidal air of each 
breath to be only 175cc With the Marshall Hall 
method the exchange of aid was 3,300 c.c, with a tidal 
air volume of 254 c.c With the Howard method the 
exchange per minute is 4,030 c.c and the tidal air 
volume 310 c.c With his own method he was able to 
pump through the lungs per minute 6,760 c.c, showing 
a tidal air volume of 520 c.c He, therefore, believes 
that this is the most efficient method of performing 
artificial respiration. He states that the advantages 
are : "1, it is fully efficient ; 2, it can be performed with- 
out fatigue by a single individual; 3, it is simple and 
easily learned; 4, it allows the tongue to fall for- 
ward, and the mucus and water to escape from the 
mouth, so that the tendency of these to block the pas- 
sage of air, which is inherent to the supine position, 
is altogether obviated." 

This subject was discussed at considerable length by 
Professor Schafer in The Journal of the American 
Medical Association, Sept. 5, 1908, page 801. 

In treating these cases it is important to preserve so 
far as possible the warmth of the patient. Woolen 
blankets should be obtained, and, after the surface of 
the body has been thoroughly dried, wrapped about 
him. While artificial respiration is being employed, 
friction of the surface of the body, especially from the 
extremities toward the center, should be carefully but 
not roughly done. It is recommended that artificial 
respiration should be continued for from one to two 
hours, but it seems that there is very little use in con- 
tinuing efforts to restore respiration after the action of 
the heart has ceased. As long as the action of the heart 
continues the artificial respiration should be continued, 
regularly and systematically. 

Some hospitals are establishing apparatus for pro- 
moting and compelling respiration in patients who have 
from ether, chloroform, or other causes, ceased to 
breathe. In the consideration of gas poisoning it was 
pointed out that the use of these devices may at times 



500 TRINITROTOLUENE POISONING 

be attended with danger. In selecting such devices 
for permanent installation, physicians should advise 
only those of simple mechanism and guaranteed safety. 

TRINITROTOLUENE POISONING 

In ammunition factories, trinitrotoluene, one of the 
high explosives employed, has been found to be dan- 
gerous to the health of a minority of workers coming 
in contact with it, and has proved fatal from toxic 
jaundice. The matter has become so important that 
the medical inspector of factories has prepared for 
the benefit of practitioners a paper on the chemistry 
of trinitrotoluene (or T. N. T., as it is designated), 
its method of absorption, the symptoms produced by it, 
the precautions to be taken against poisoning, the 
method of treatment, and the differential diagnosis 
of trinitrotoluene poisoning from that of dinitroben- 
zene, tetryl and lyddite, the latter a picric acid deriva- 
tive. 

Trinitrotoluene is a high explosive obtained by 
nitrating toluene, from coal tar, a benzene compound 
in which one hydrogen atom is replaced by CH g , and 
in which during the process of nitrating three other 
hydrogen atoms are replaced by the nitro radical, N0 2 . 
The product is solid at ordinary temperatures and may 
be reduced to a fine powder, melts at 80 C, and 
sublimes when melted. 

When the skin or hair comes in contact with trini- 
trotoluene, a characteristic yellow or tawny orange 
stain is produced, which is removable by oils, greases, 
acetone, ether, benzene and other compounds, but not 
by water. When trinitrotoluene is treated with alco- 
holic solution of potassium hydroxid, a deep pink color, 
changing to purple and then to brown, is produced, and 
this reaction is employed in testing for trinitrotoluene 
in urine, after the latter is treated to release the tri- 
nitrotoluene from its combinations — a rather compli- 
cated procedure. 

Trinitrotoluene can be absorbed to a dangerous 
extent by the skin, and as fine dust or as sublimate will 
reach the mucous membranes of the nose and mouth, 
or perhaps even the lungs, and may be swallowed with 
the secretions of the mouth, nose and throat. It may 



TRINITROTOLUENE POISONING 501 

be recovered from the feces unchanged in most work- 
ers, and in many from the urine, but only in combina- 
tion. Among the symptoms it produces are dermatitis, 
much like that produced by other irritants, increased 
by flushing and perspiration and by friction ; gastritis, 
with abdominal pain, vomiting, constipation which is 
constant, flatulence and distention; and blood changes 
similar to those of dinitrobenzene poisoning, with the 
presence of methemoglobin, though cyanosis and 
breathlessness are less evident. Cell degeneration is 
readily produced by trinitrotoluene, and when the liver 
is involved toxic jaundice results, though in only a few 
cases. Evidence of gradual absorption is shown by 
pallor of the face and an ashen gray color of the lips ; 
sometimes the lips and tongue are deeply cyanosed. 
Jaundice may be conjunctival or general, and often 
appears suddenly during the first four weeks of expo- 
sure. Liver dulness is variable, ascites is sometimes 
present, respiratory distress is not noticeable when the 
patient is in bed, and pyrexia has occasionally been 
observed in severe cases ; but neither bradycardia nor 
pruritus is common. Two deaths from anemia unasso- 
ciated with jaundice have been reported, with reduc- 
tion of red cells to one million, of unequal size, but no 
poikilocytes or nucleated reds. Microscopic examina- 
tion excluded pernicious anemia. Death resulted from 
hemolytic aplastic anemia, the blood-forming marrow 
having been greatly reduced. 

Points of differential diagnosis are the characteristic 
appearance already described, the character and situa- 
tion of the abdominal pain, and the presence of consti- 
pation and abdominal distention. It may be confused 
with other gastric disturbances, and must be distin- 
guished from tetryl and picric acid poisoning, the for- 
mer staining the skin a yellow or apricot color, the 
latter a canary yellow or greenish yellow ; both set up 
a dermatitis similar to that of trinitrotoluene, but the 
constitutional symptoms are not pronounced, and toxic 
jaundice from them has not been reported. 

Postmortem, the outstanding feature is atrophy of 
the liver, which in some cases is reduced to half the 
normal weight*. Microscopically, the greater part of 
the liver tissue is found to have undergone complete 
destruction, associated with proliferation of fibrous tis- 



502 MERCURIC CHLORID POISONING 

sue. The kidneys are large and icteric, the cortex 
bulges, the labyrinths are frequently yellow, there is 
engorgement of the pyramids, and cloudy swelling and 
fatty degeneration of the tubules. 

Treatment in the absence of jaundice is simple: 
removal from contact, rest in bed for a day or two, a 
diet consisting of milk, milk puddings, fruit and green 
vegetables, demulcent drinks, such as barley water, tea 
and coffee; for the constipation, vegetable laxatives 
and cascara, with a mixture containing sodium sul- 
phate, potassium citrate and sodium bicarbonate as a 
routine measure. In jaundice cases, absolute rest in 
bed is essential; milk diet, small in quantity at first, 
gradually increasing to 4 pints a day ; the bowels must 
be kept loose, preferably by a mixture containing mag- 
nesium carbonate, magnesium sulphate and peppermint 
water, repeatedly given. In jaundice with marked 
toxic symptoms the prognosis is grave. Alkali-pro- 
ducing drugs, such as the citrates and bicarbonates, 
should be given to overcome the tendency to acid 
intoxication. Rectal and intravenous saline injections 
have a place in the treatment of severe cases. 

MERCURIC CHLORID POISONING 

The U. S. Hygienic Laboratory collected from Jan. 1 
to June 30, 1917, reports of 707 cases of mercurial 
poisoning, of which sixty-one were fatal. Most of 
the epidemic of mercurial poisoning dates back to 
a case which was given considerable attention by the 
lay press, thus advertising mercuric chlorid as a 
method of poisoning and making the added unfor- 
tunate error of stating that death by this method was 
painless and easy. Poisoning also occurs not infre- 
quently following the use of mercurial vaginal douches 
or injections; in some instances there has been a fatal 
result. 

Sansum (Jour. A. M. A., March 23, 1918, p. 824) 
found that the minimum uniformly lethal intrave- 
nous dose of mercuric chlorid in dogs was 4 mg. per 
kilogram of body weight; a dose which corresponds 
approximately to the smallest dose of mercuric chlo- 
rid which has been known to cause death in man. 
Such a dose in dogs failed to produce anuria, whereas 



MERCURIC CHLORID POISONING 503 

this symptom was brought about by the injection of 
5 mg. per kilogram. 

SYMPTOMS. 

The first symptoms of mercuric chlorid poisoning 
are epigastric pain, nausea and vomiting, the vomitus 
sometimes containing more or less blood. The gastric 
symptoms may be almost entirely relieved by proper 
treatment, the success of which depends on the length 
of time between the ingestion of the poison and the 
treatment, and on whether the stomach was full or 
empty when the poison reached it. Diarrhea and signs 
of duodenal inflammation occur within a few hours, 
unless the poison was quickly vomited. If much mer- 
cury has been absorbed, stomatitis occurs on the 
second day. 

If a tangible amount of mercury has been absorbed, 
there is soon a gradual diminution in the amount of 
urine passed, and after the first or second day there 
may be complete suppression. As noted in other acute 
metallic poisonings, total suppression of urine may 
not cause convulsions, as it ordinarily does in uremia, 
probably because some of the detoxicating functions 
of the kidneys may still be operative. After several 
days delirium may occur, followed by coma, while 
the heart shows gradual failure. ' 

If acute nephritis does not cause death, ulcerative 
colitis with hemorrhages from the bowels may prove 
fatal, even after a lapse of several weeks. 

TREATMENT 

The following treatment of mercuric chlorid poison- 
ing is founded on the therapeutic results and labora- 
tory findings of Lambert and Patterson (Arch. Int. 
Med., November, 1915, p. 865) and of Fantus (Jour. 
Lab. and Clin. Med., 1916, 1, 879; ibid, 1917, 2, 722). 
It is best immediately to examine the first material 
expelled from the stomach either by vomiting or by 
lavage, and to examine the urine for mercury, as the 
patient may not have taken mercuric chlorid as he 
imagines. The patient is first given the whites of 
several eggs and the stomach is then washed out. He 
is then given a pint of egg albumin water, and the 
stomach again washed out. 



504 TREATMENT OF BICHLORID POISONING 

According to Fantus, a tablet composed of sodium 
phosphite, 0.36 gm., and sodium acetate, 0.24 gm., 
should be dissolved and administered as soon as pos- 
sible. If this drug cannot be obtained, the following 
solution should be substituted : sodium hypophosphite, 
1 gm. ; hydrogen peroxid, 5 c.c, and water, 10 c.c. If 
the amount of poison swallowed is known, ten times 
that amount of hypophosphite should be given. As 
this dosage of hypophosphite might be large, it should 
immediately be followed by lavage with warm water 
and a greatly diluted solution of the antidote. This 
may be followed by a safe dose of antidote, which 
may be repeated every eight hours for several days. 
A glass of egg albumin water should also be imbibed 
every alternate hour until several doses have been 
taken. Since it has been shown that milk is worthless 
as an antidote, there seems to be no necessity for using 
milk, which curdles and causes acid. As a demulcent, 
starch water, slippery elm, or flaxseed tea may be 
used. A gram of sodium acetate, dissolved in sweet- 
ened water, should be taken every three hours, for 
a day or two, being omitted at such times as it comes 
in conflict with the antidote. 

Lambert and Patterson's recommendation of rectal 
irrigation is important. They use the drop method 
of rectal irrigation, with a solution of potassium 
acetate, 4 gm. (a dram) to the pint. It might be well 
to substitute sodium acetate for the potassium acetate, 
as in all poisoning and in all serious conditions, sodium 
salts are safer than potassium salts, as this solution 
is more or less rapidly absorbed and generally causes 
diuresis. The colon should also be thoroughly irri- 
gated twice daily to remove whatever mercury may 
have been there deposited or which may have reached 
the colon through the bowels. As there occurs a 
resecretion of mercury into the stomach, it should be 
washed out twice daily during the first few days unless 
the patient vomits repeatedly when given warm water. 
Lambert and Patterson affirm that it is advisable to 
continue the colonic drip enteroclysis day and night, 
at short intervals, even though it is intensely disagree- 
able to the patient until two examinations of the urine 
on successive days have given a negative test for mer- 



TREATMENT OF BICHLORID POISONING 505 

cury. They also assert that if excessive doses of mer- 
curic chlorid have been absorbed, or if the kidneys 
were previously diseased, the treatment should con- 
tinue for a longer period, as long as three weeks, if 
necessary. 

If the kidneys have become seriously involved and 
suppression is present when a patient first comes under 
observation, the prognosis, although very serious, is 
not hopeless. Lambert and Patterson advise a daily 
sweat in a hot pack. This treatment, and also fre- 
quently repeated stomach washings, depends on the 
condition of the circulation — if the heart is weak and 
the circulation poor, the hot pack may be inadvisable. 

Wilms and Holm have recommended calcium sul- 
phid as an antidote, Hall has suggested the use of 
potassium iodid and quinin hydrochlorid, and Weiss, 
basing his treatment on Fischer's hypothesis, has given 
the Fischer treatment and combined with it oral admin- 
istration of "imperial drink" or other mixtures to 
keep the urine alkaline. MacNider found that the 
nephritis of mercuric chlorid poisoning was constantly 
associated with and showed parallelism to the phe- 
nomena of acidosis and this he states is an indication 
for alkaline treatment. 

Sansum found that in cases of anuria from experi- 
mental mercuric chlorid poisoning, all attempts to 
reestablish the flow of urine by intravenous adminis- 
tration of strongly diuretic solutions failed. It is his 
belief that in the reported cured cases a fatal dose 
was not received because the early treatment prevented 
absorption of any considerable amount of mercury. 
The symptoms were those of a relatively mild grade 
of tissue poisoning, compatible with recovery without 
accelerated diuresis. "It would appear" he says, "as 
though the success of the treatment may have been due 
chiefly to the factors of delayed absorption and has- 
tened elimination from the alimentary tract rather than 
the diuresis and sweating, although on the basis of 
the present experiments on dogs, no conclusion could 
be drawn as to the value of the sweating." In the 
same way he found that intravenous injections of the 
sodium acetate sodium phosphite solutions failed to 
save the lives of dogs poisoned with intravenous injec- 



506 TREATMENT OF BICHLORID POISONING 

tions of minimum uniformly lethal doses of mercuric 
chlorid. He concludes finally: 

1. There is no sound experimental basis for the 
belief that the promotion of free diuresis contributes 
materially to the chances of recovery in mercuric 
chlorid poisoning, and this phase of treatment should 
not be permitted to obscure that which is more essen- 
tial. 2. Combined treatments which involve sweating, 
diuresis and increased elimination from the bowel 
probably owe their value chiefly to the latter effort. 3. 
It would appear in the light of the present study 
that when 4 mg. or more of mercuric chlorid per kilo- 
gram of body weight has entered the tissues at large, 
death regularly occurs, and that we have no adequate 
grounds for believing that death is preventable by 
any known form of treatment. Whereas, subsequent 
studies may add to our knowledge, it would appear 
that persons who have recovered from mercuric 
chlorid poisoning owe their lives to the fact that a 
lethal dose has never gained access to the extraportal 
circulation. Practical therapeutic efforts should be 
directed frankly toward the accomplishment of two 
things: (a) mechanical removal of the poison from 
the lumen of the alimentary tract; (b) antidoting the 
poison before it leaves the portal circuit, that is, par- 
ticularly before absorption. 

However, Sansum's results should not cause the 
physician confronted with one of these well-nigh hope- 
less cases to relax his efforts. Everything possible 
should be done that seems scientifically practical to 
relieve the various symptoms as they arise. 



DISEASES OF THE EYE 



OPHTHALMIA NEONATORUM 

The prevention of this inflammation of the eye is of 
national importance and should be understood and car- 
ried out by every practitioner who takes charge of 
obstetric cases. The use of Crede's method has greatly 
reduced the frequency of this disease, and shown that 
ophthalmia neonatorium is preventable. 

PROPHYLAXIS 

The child's first bath is of the utmost importance. 
The eyelids must be gently wiped free from the mucus 
and other matter covering them, a piece of absorbent 
cotton dipped in boric acid solution serving for this 
purpose. The head must then be cared for, a soft 
wash cloth wrung almost dry from warm water being 
employed. Water should not be poured over the head 
so that the secretion is washed into the eyes. When 
the general bath is given the water that is used for the 
bath must not be used about the head. After thor- 
oughly cleansing the eyes, instill a drop of a 1 per cent, 
nitrate of silver solution into each eye. While Crede 
advised the use of a 2 per cent, solution, it is generally 
believed that the 1 per cent, is of sufficient strength. 
This may be followed by a little physiologic saline 
solution or a drop of adrenalin chlorid solution 
(1 : 5,000). This "stops the pain and neutralizes the 
further action of the silver." Other more modern 
silver preparations have also been advised, as 25 per 
cent, argyrol or 10 per cent, protargol, but they are 
probably not so reliable as the silver nitrate. 

Special precautions should be taken to prevent infec- 
tion of those attendant on the patient. The noninfected 
eye should also be protected by the wearing of a shield. 
Buller's shield is a watch glass held in place over the 
eye by the use of adhesive strips and a layer of col- 
lodion. 



508 OPHTHALMIA NEONATORUM 

ACTIVE TREATMENT 

If in spite of such prophylactic treatment the con- 
junctivae become inflamed, they should be thoroughly 
cleansed. The lid of the eye is gently raised, all pres- 
sure being avoided, and the tip of a soft rubber bulb 
syringe is inserted under the upper lid. Slowly and 
gently the eye is irrigated with a saturated cold boric 
acid solution to wash out all purulent matter. This 
should be done every fifteen minutes if the discharge 
is profuse, or less often if it is not copious. Mercuric 
chlorid (1:10,000), normal saline solution, or sterile 
water may also be used as cleansing agents. 

Iced compresses of boric acid solution may be applied 
to secure lessened inflammation and relief from pain. 
Continuous refrigeration, however, should be avoided 
to prevent loss of nutrition which may result from it. 
If the cornea is involved hot applications and instilla- 
tion of atropin is generally advised. 

In the treatment of these cases silver nitrate is the 
drug of chief reliance. Once each day during the 
course, especially While there is a purulent discharge, 
a 1 or 2 per cent, solution of silver nitrate should be 
brushed on the everted conjunctiva. If eversion of the 
lids is extremely painful, they may, at first, simply be 
raised and the silver nitrate solution applied with a 
well-protected swab. 

The eye is cleaned as often as necessary to keep it 
reasonably free of pus, be it every twenty minutes or 
every three hours. The lids are wiped clean and then 
separated with the fingers ; the conjunctival sac is 
washed out with boric acid squeezed from a pledget 
of cotton, several drops of one of the milder silver 
salts are instilled, the excess wiped away, and the lids 
are liberally smeared with some bland salve, such as 
boric acid ointment. Injury to the corneal epithelium 
is most carefully guarded against. In the later stage 
of the disease, if the conjunctiva becomes boggy and 
little improvement is taking place, silver nitrate and 
zinc sulphate are called into use. 

Regarding the silver preparation to be used in the 
acute stages of the disease, a non-irritating drug is 
indicated; the stronger silver preparations, such as 
nitrate do good in inflammations by their ability to set 



BLEPHARITIS 509 

up a reaction and draw in protective substances from 
the neighboring tissue ; and that their place is therefore 
in those inflammations in which a sufficient reaction 
does not already exist. This is not the case in gonor- 
rheal ophthalmia, since the reaction is often too great 
(especially in. the adult form) for the conjunctival 
circulation to take care of. 

A number of physicians have reported the successful 
use of Mercurochrome-220 (N. N. R.). A 2 per cent, 
solution is freely instilled into the eye. It produces a 
slight burning effect for a few seconds. It produces 
a red stain, but will not produce a permanent stain 
such as is occasionally produced by the silver salts, 
argyrol and protargol. 

If the discharge and inflammation persist, it may be 
necessary to consider surgical procedures or specific 
treatment of the complications. The disease is a serious 
one and the services of a specialist should be procured 
early in its course. 

BLEPHARITIS 

The occurrence of inflammations of the lids has 
been associated with numerous causes, chiefly general 
debilitated condition of the body, following infectious 
diseases, lack of cleanliness and errors of refraction. 
Bad hygienic surroundings, lack of sleep, irritating 
atmosphere, due to dust, heat, smoke, or other causes 
and insufficient light also play a part in some cases. 

The correction of these general causes is important, 
more important perhaps than any local treatment. 
Local cleanliness and removal of any bad eye-habits 
should be attempted and persisted in. Errors of 
refraction should be referred to a competent refrac- 
tionist for correction. The occupation of the patient 
as a source of irritation should be thoroughly investi- 
gated. 

In securing cleanliness of the eyes, the edges oi the 
lids should be washed with soap and water, or water 
and borax, or solutions of hydrogen peroxid, removing 
all crusts if possible without serious injury. As a 
sedative eye wash may be used : 



510 BLEPHARITIS 

Gm. or C.c. 

I£ Acidi borici 

Aquae camphorae 15 

Aquae destillatae q. s. ad 25 

M. Sig. : Place two or three drops in each eye three or 
four times a day. 



25 gr. v 

fl3v 
flgi 






Massage of the lids is a therapeutic measure of wide 
usage in this condition. Among various ointments 
advised adeps lanae hydrosus (lanolin) and 2 per cent, 
yellow oxid of mercury have been commended. Gentle 
massage by horizontal stroking movements on the 
closed lids with the index finger, carried from the inner 
to the outer angle of the palpebral fissure, and lasting 
from three to five minutes, relieves venous congestion 
and stimulates the activity of the lymphatics, and 
absorption of inflammatory products is increased. This 
ointment, or petrolatum, if preferred, will soften the 
scales and allow them to be removed, thus aiding in get- 
ting rid of the blepharitis. Such massage is best done at 
bedtime, when some of the ointment may be left on the 
lids. In the morning the ointment may be washed off, 
and with it will come many of the scales. The yellow 
oxid of mercury seems to be a most valuable medica- 
ment for healing the lesions of this inflammation. It 
may be ordered as follows : 

Gm. 

I£ Hydrargyri oxidi flavi 10 gr. i 

Olei olivae q. s. or 

Petrolati 10 3 ii 

M. Sig. : Apply at bedtime as directed. 

This makes 1 per cent, of the yellow oxid of mer- 
cury. It should be remembered that the official yellow 
oxid of mercury ointment is 10 per cent. 

When there is much itching of the lids, a salicylic 
acid ointment may be useful: 

Gm. 

Ifc Acidi salicylici 115 or gr. ii 

Adipis lanae hydrosi 10] 3 ii 

M. Sig. : Apply as directed. 

If itching is very marked Brav has recommended a 
tannic acid ointment, as : 

Gm. 

B Acidi tannici 115 or gr. ii 

Petrolati 10| 3 ii 

M. Sig : Use as directed. 



HORDEOLUM 511 

In treating the ulcerative type of blepharitis, or 
more severe types, it may be necessary to pull out all 
the eyelashes before undertaking the treatment. The 
use of silver nitrate is advised in these severe forms, 
and applications are made once daily with a 1 or 2 per 
cent, solution. Again it may be said that severe disease 
of the eyes is best referred to the specialist if competent 
specialists are available. 

HORDEOLUM (STYE) 

The stye is a fairly common form of eye infection. 
It is ordinarily a staphylococcus infection of a seba- 
ceous follicle, around the lash, but may occur inside the 
lid as an internal hordeolum or suppurating chalazion. 

As the stye is, as has been stated, primarily a staphy- 
lococcus infection, its source should be looked for in 
lowered resistance due to uncleanliness, general debility 
and errors of refraction. 

Attempts may be made to abort the stye by cofd 
applications, but ordinarily when seen it will be too far 
advanced for such a procedure. As in any other local 
infection, hot compresses may then be applied and 
when pus manifests its presence by a yellowish appear- 
ance the pus should be evacuated, incising as freely as 
necessary, and the area may be cleaned up by a mild 
antiseptic washing. 

If the hordeolums occur in crops or tend to recur 
frequently, general treatment in hygienic matters is 
indicated, and the use of autogenous vaccines may 
serve to create a more or less permanent cure wifh 
immunity from further attacks. 

IRITIS 

Inflammation of the iris may be acute or chronic, 
primary or secondary in its origin, and associated etio- 
logically with syphilis, rheumatism, tuberculosis, gout, 
gonorrhea, malaria, diabetes, anemia or any of the 
acute exanthems. Iritis seldom occurs without a sim- 
ultaneous inflammation of the ciliary body. 

Besides the actual pathologic changes in the iris 
and neighboring structures there are ordinarily pain, 
lacrimation, interference with vision and a fear of 
light. Ordinarily the duration of the disease is from 
several weeks to several months. 



512 IRITIS 

TREATMENT 

In the treatment of iritis both eyes should be placed 
at rest; smoked glasses may be worn. The patient's 
general condition should be regulated, constipation pre- 
vented and sufficient sleep secured by the administra- 
tion of hypnotics or morphin if necessary. When the 
pain subsides the patient should be in the open air as 
much as possible. 

The primary condition associated with the ocular 
inflammation should be treated energetically. Syphilis, 
tuberculosis, gout and focal infection are all conditions 
which demand active scientific treatment. If a focus 
of infection is found it should be eradicated. 

The most important drug in the treatment of iritis 
is atropin, which should be used in sufficient dosage to 
produce a full physiologic effect on the pupil. In chil- 
dren it should be used with care to prevent poisoning. 
In general a 1 per cent, solution may be used, of which 
one drop is instilled into the eye every hour until the 
pupil is dilated. Following this one drop every eight 
hours is used to secure continued action. In children a 
0.5 or 0.25 per cent, solution is advisable. When atropin 
is not well borne and causes unpleasant symptoms, 
the following solutions may be tried: 

Gm. or C.c. 

5 Duboisinae sulphatis 1035 or gr. Vz 

Aquae destillatae 10] A3 iiss 

M. Sig. : One drop instilled in the affected eye every eight 
hours. 

Or: 

Gm. or C.c. 
Ifc Scopolaminae hydrobromidi.. 1015 or gr. X A 

Aquae destillatae 8| A3 ii 

M. Sig. : One drop instilled into the affected eye three times 
daily. 

If undesirable symptoms from the action of atropin 
occur, such as very uncomfortable drying of the throat, 
palpitation, flushing of the face, and cerebral excita- 
tion, then the stronger atropins must be discarded and 
homatropin used. 



TREATMENT OF IRITIS 513 

Gm. or C.c. 
Ifc Homatropinae hydrobromidi. 140 or gr. vi 

Aquae destillatae 10] A3 iiss 

M. Sig. :One drop in the affected eye every hour. 
[If both eyes are inflamed, the strength of the above 
preparations, in order for a drop to be used in each eye, 
must be reduced.] 

During the course of the inflammation the tension 
of the eye must be carefully watched lest glaucoma 
develop, though a temporary increase in intra-ocular 
pressure is often seen. As soon as the eye shows 
increased tension, give absolute rest and stop the 
atropin. If the tension does not then in a few hours 
decrease eserin may be used : 

Gm. or C.c. 
B Physostigminae sulphatis. . . 103 or gr. V2 

Aquae destillatae 8| A3 ii 

M. Sig. : One drop in the affected eye every hour. 

It should seldom be necessary to have recourse to 
this treatment, and it is rarely necessary to employ 
surgery to prevent glaucoma from iritis. 

The value of atropin in iritis is to dilate the pupil 
and thus to prevent posterior synechiae. It also con- 
tracts the iris, thus reducing congestion, and paralyzes 
the ciliary muscles, thus giving the iris absolute rest. 

If the pain from the inflammation is not stopped by 
the atropin, hot moist compresses, frequently changed, 
should be employed. Poultices are not needed. If 
the deep-seated pain in the orbit continues, so as to pre- 
vent sleep, morphin must be used, and best hypoder- 
matically. 

Cocain may be combined with atropin at times, as : 

Gm. or C.c. 

B Cocainae hydrochloridi |03 

Atropinae sulphatis aa 03 or gr. ss 

Aquae destillatae 8| A3 ii 

M. Sig. : One drop instilled into the affected eye, every 
three or four hours, if necessary. 

The treatment of hypopyon or posterior synechia is 
a subject for a specialist. 

As it is stated that at least 50 per cent, of iritis is 
caused by syphilis and that mostly in the secondary 
stage, constitutional treatment during such iritis is that 
of the syphilis, and mercury is the important drug. 



514 FLOATING SPOTS 

BURNS OF THE EYE FROM LIME 

This form of accident occurs quite frequently, and is 
ordinarily followed by very grave results. The most 
serious and important sequel is the adherence of the 
lid to the globe (symblepharon) when there are two 
opposing raw surfaces. If the patient is seen immedi- 
ately after the accident, the first step in the treatment 
is to drop into the conjunctival sac a few drops of a 
1 per cent, solution of holocain, or of a 4 per cent, solu- 
tion of cocain, in order to relieve the pain, which is 
usually intense, and then to remove all the remaining 
particles of lime as quickly as possible. The irrigating 
fluid should be a weak solution of vinegar, to neutralize 
the caustic effect of the lime. Subsequently cold appli- 
cations should be applied to the closed lids, and a mild 
antiseptic, such as a 3 per cent, boric acid solution, 
dropped into the eye every two or three hours. If the 
burn is at all extensive, the conjunctival sac should be 
filled with an antiseptic ointment, which not only 
relieves the pain, but also prevents adhesion of the 
opposing surfaces. One of the best preparations for 
this purpose is a mercuric chlorid ointment which 
consists of mercuric chlorid (1:10,000) in petrolatum. 
Severe burns from lime, resulting in complete opacity 
of the cornea, have been treated — in addition to the 
usual local treatment — by subcutaneous injections of 
sodium cacodylate (from 1 to 3 grains at a dose) with 
perfect results. 

After emergency treatment has been administered, 
if the case appears to be at all severe, the patient may 
well be referred to a specialist in such conditions. 

FLOATING SPOTS— MUSCAE VOLITANTES 

The spots floating in the line of vision are not patho- 
logic formations in the vitreous, but are shadows cast 
on the retina by cells in the vitreous. They have been 
attributed to irritation of the retina, or congestion of 
the choroid, as well as to eye strain and to constitutional 
disturbances. Hyperesthesia of the retina and errors 
of refraction have also been incriminated as causes of 
this condition. These spots indicate the need of exam- 



FLOATING SPOTS 515 

ination for errors of refraction and for improving the 
general condition, otherwise floating spots — muscae 
volitantes — are not of importance. Of course, the 
vitreous should be examined for the presence of 
opacities of abnormal character. 



DISEASES OF THE EAR 



OTITIS MEDIA 

All kinds of bacteria may reach the middle ear, but 
the most frequent infections are the streptococcic and 
the pneumococcic. In a healthy ear the bacteria reach 
the tympanic cavity through the eustachian tube, 
and this presupposes a nasopharyngeal infection and 
inflammation. Obstruction at the mouths of the eus- 
tachian tubes, or swelling in the tubes, then inhibits 
the normal aeration of the tympanic chamber and pre- 
disposes to infection of the middle ear. Hence pro- 
phylaxis of middle-ear inflammations consists in the 
removal of obstructive adenoids in the nasopharynx, 
in the removal . of obstructive hypertrophies of the 
nasal passages so as to cause proper nasal respiration 
and the correction, so far as possible, of nasal and 
nasopharyngeal chronic inflammations. 

In acute inflammations of the nose and nasopharynx 
when the eustachian tubes are likely to become 
obstructed and bacteria are likely to reach the middle 
ear, a proper cleansing of the nose and nasopharynx 
with warm, mildly antiseptic and alkaline sprays and 
gargles is the proper treatment. Nasal douches as 
generally applied are likely to force fluid, pus and 
bacteria into the middle ear, in fact, a douche should 
never be taken through the nostrils with any but the 
most gentle pressure. Snufnng mild, warm, alkaline 
fluids through the nostrils, or gently spraying and then 
snufnng, or possibly the pouring of such a fluid from a 
spoon or small vial into the nostrils can do nothing. but 
good and no harm to the eustachian tubes. Or gentle 
spraying into the nasopharynx with such solutions or 
gargling and throwing the head forward so that the 
liquid washes the roof of the pharynx, will also remove 
products of inflammation, pus and mucus from these 
parts and from the mouths of the eustachian tubes. 

It is important to diagnose infection in the middle 
ear early in order that mastoid complication be fore- 
stalled. As emphasized by La Fetra (Jour. A. M. A. 



OTITIS MEDIA 517 

74: 1222, 1920), routine examination of the ears should 
be made in every child when ill. Complaint of pain 
in the ear, if present, is of course important; but young 
infants do not well localize their pains. A baby will 
cry and put his hand on the abdomen, and complain 
of pain in the stomach, when examination will reveal 
a bulging drum as the cause of the pain. Rolling the 
head or putting the hand to the ear are suggestive, but 
often have no significance. Absence of any complaint 
of pain or even of general restlessness is no proof that 
the ear is not inflamed. Temperature elevation is 
nearly always present, but this also, like pain, may be 
absent even when the drum is bulging. Tenderness in 
front of the ear is a reliable sign, but this, too, is occa- 
sionally lacking even when there is high temperature 
and bulging of the drum. Moreover, many children 
deny tenderness, in spite of the involuntary wincing of 
the mouth. Stiffness of the neck is occasionally present 
even without enlarged lymph nodes under the mastoid 
muscle and without mastoiditis. La Fetra sums up 
the indications of middle ear disease by the statement 
that a bulging drum is the only diagnostic sign. On 
examination, retraction of the drum and in addition 
some redness is frequently the first sign of inflamma- 
tion in the rhinopharynx and often confirms a suspicion 
of acute rhinitis as cause for fever up to 102 or 103 F. 
when there is as yet no running or stuffiness of the 
nose. The next sign of ear involvement is some red- 
ness along the malleus, and the next, some fulness and 
redness of Shrapnell's membrane. These signs are 
present so commonly with head colds in children, and 
subside so readily, that this small degree of otitis can 
be considered a very common accompaniment of acute 
rhinitis. The next signs that appear mean an otitis 
media, namely, redness and bulging of the drum mem- 
brane, first behind and later in front. Occasionally the 
drum looks only gray, owing to thickened epithelium, 
which must be removed to get a view of the drum 
itself. The retraction meanwhile increases, and the 
appearance of the drum is that of a small red ring or 
doughnut. When accompanied by a high temperature, 
these signs are sufficient justification for incision of 
the drum ; but by far the larger number of such cases 



518 OTITIS MEDIA 

will subside in a day or so if the nostrils are treated 
by a weak epinephrin solution or if hot irrigations of 
the ear are employed. 

If middle-ear congestion occurs the diagnosis must 
be made as to whether serum or other fluid is present 
or not. If fluid is present, as shown by bulging of the 
tympanic membrane and by deafness, incision of the 
drum must be immediately made. If no fluid is present 
in the tympanic cavity, but the drum shows conges- 
tion and there is pain, the following ear drops may be 
used: 

Gm. or C.c. 

Ifc Acidi borici 1 gr. xv 

Glycerini 25 or AS i 

Aquae q. s. ad 50 AS ii 

M. Sig. : Warm, and pour half a teaspoon ful into the ear 
once in three or four hours. 

Gm. or C.c. 

Ifc Phenolis II or gr. xv 

Glycerini 25| Si 

M. Sig. : Warm, and pour several drops into the ear once 
in three or four hours. Then plug with cotton. 

This fluid should be held in the ear a minute or two 
and then allowed to run out. The outer part of the 
canal is then gently dried with absorbent cotton and a 
plug of cotton left in the orifice. 

It should again be emphasized that treatment, even 
as simple as the above, should only be used to relieve 
congestion and pain, but such temporizing measures 
should not be used if the drum is bulging and there is 
fluid in the middle ear. The only treatment for this 
condition is incision. 

La Fetra believes that paracentesis should be done 
under anesthesia, preferably chloroform, though an 
exception may be made to this rule if the patient is an 
infant and only one drum is to be incised. The incision 
should be a J or U shape, and should be carried well 
upward. Irrigation with hot boric acid solutions imme- 
diately after incision is of advantage, and it is always 
satisfactory to hear the child gulp or swallow during 
this irrigation, as this shows a free opening through 
the drum, with passage of the irrigation fluid into the 
throat. The temperature, the pain, the tenderness in 
front of the tragus, and the tenderness of the tip of the 



OTITIS MEDIA 519 

mastoid — if that has been present — should all subside 
after two or three days. It is quite common, however, 
for the temperature to remain elevated until the dis- 
charge becomes purulent. This may be two or three 
days after the incision. 

Treatment after incision or after perforation of the 
drum, or of mastoid congestion, and of mastoid inflam- 
mation, belongs to the specialist. The restoration of a 
perfect drum and the recovery of perfect hearing after 
middle-ear disturbance, and especially after mastoid 
inflammation, marks a success as great as in any branch 
of medicine. The general physician's duty ends when 
he has referred a patient with either acute or chronic 
ear disturbance to the specialist, and after he has 
impressed on his patient that the time to prevent, if 
possible, deafness and the danger of a possible cere- 
bral abscess is now. If the patient neglects his own 
treatment after warnings, he has only himself to 
blame, but let him never be allowed the opportunity 
to blame his physician. * 



DISEASES OF THE SKIN 



PRURITUS: ITCHING 

Pruritus, or itching, represents one of the most puz- 
zling problems in medicine. The clinical manifesta- 
tions are connected with the terminations of the sensory 
nerves in the epidermis. Many believe that it is asso- 
ciated with hyperemia and inflammation, this condition 
sometimes resulting in atrophy, with a continuance of 
itching. There are many reasons for believing that 
these pathologic conditions are not the ultimate cause 
of the itching in many cases. For example, Oxyuris 
vermicularis, or pin-worm, causes pruritus in children 
without any local lesion or disturbance in the nutrition 
of the skin evident on inspection, and the pruritus 
is probably not due to the presence of a foreign body 
on the skin. It is also a question whether the itching 
produced by pediculi, or lice, is s due alone to their 
presence on the skin in a quiescent state or even in 
active movement. The rapidity with which the itch- 
ing in scabies subsides under sulphur treatment indi- 
cates that it is due to something besides the presence 
of a foreign body. Itching produced by a bite of a 
mosquito is out of all proportion to the local conges- 
tion and inflammation and is no doubt due to some 
poison injected by the mosquito. The itching associ- 
ated with jaundice dependent on obstruction to the 
flow of bile into the intestine is due to the irritation of 
the ends of the sensory nerves by some substance 
absorbed from the bile into the blood. The itching in 
urticaria due usually to the ingestion of some unusual 
article of food, is probably caused by some poison 
carried to the nerve-endings in the blood as in the case 
of jaundice. 

It will be noted that many diseases accompanied by 
congestion and inflammation of the skin cause itching, 
but it is a curious fact that syphilis, which is con- 
stantly accompanied by cutaneous lesions, has the 
striking characteristic that its skin lesions are usually 
unaccompanied by itching. 



PRURITUS 521 

With certain general diseases pruritus is a common 
symptom, especially diabetes and gout. These diseases 
are all characterized by the presence in the blood 
of chemical bodies, Avhich are ordinarily not there. 

It is taught that pruritus may be of central origin. 
It is asserted to be of not infrequent occurrence in 
hypochondriasis and hysteria. Still another form is 
described as being of psychic origin, and is seen in 
insane persons who have hallucinations of the presence 
of parasites, such as pediculi, on the skin; hallucina- 
tions which it is often difficult to remove, and which 
are sometimes removed only after repeated applica- 
tions of antipruritic remedies. 

MANAGEMENT 

In undertaking the treatment of a case of pruritus it 
is necessary to investigate every organ of the body so 
as to restore it to normal action, if possible. First, 
the condition of the digestive organs must be care- 
fully investigated, and the diet must be carefully 
regulated. There are two types of people in whom 
pruritus is seen: one is the stout, robust, plethoric 
person who is continually overeating, and the other 
is the thin, hungry person who is continually starving 
himself. In the case of the former the diet should be 
cut down. The protein substances should be greatly 
reduced, and the starches and sugars should be con- 
siderably limited. It will be found that certain articles 
of food are not completely digested but give rise to 
fermentation; such articles should be reduced to an 
amount that can be taken care of by the digestive 
organs. In the latter class, the thin patients, fatty 
articles of food should be advised, and an adequate 
amount of protein should be given to afford adequate 
nourishment. In both classes, fruits, especially 
oranges and grapes, will be found exceedingly useful. 

If the patient is constipated, measures should be 
taken to make the bowels act regularly and abundantly. 
A small dose of calomel, several times repeated, is 
sometimes useful for this purpose. If calomel is 
thought to be undesirable a saline, as 1 or 2 drams of 
magnesium sulphate or sodium sulphate, may be given 
in half a glassful of water in the morning before 
breakfast. 



522 TREATMENT OF PRURITUS 

ELIMINATION 

Pruritus is frequently associated with deficient elim- 
ination. If the condition of the urine is found to indi- 
cate such defective elimination, the internal use of 
alkalies will generally be found of advantage. In the 
case of the plethoric individual with a strongly acid 
urine of high specific gravity, the following prescrip- 
tion may be used : 

Gm. or C.c. 

B Potassii citratis 401 3 ix 

Aquae menthae piperitae 200] or flSvi 

M. Sig. : Two teaspoonfuls, in water, three times a day, 
after meals. 

If the above dose, three times a day, does not alka- 
lize the urine (if that is the object desired), it may 
be administered four times a day. 

Although it is admitted that pruritus is associated 
with the sensory nerves, and it is claimed that in some 
instances it is due to a disturbance of the central ner- 
vous system, no drug acting on the brain, spinal cord 
or nerve trunks is very effective in pruritus, possibly 
with a single exception of bromids. The continuous 
treatment of pruritis with bromids is inadvisable. 
Temporarily such treatment may be used. 

LOCAL APPLICATIONS 

Generally, in order to stop the itching, it is necessary 
to apply some drug to the skin, which will lessen the 
sensibility of the ends of the nerves which are in 
trouble. Several drugs are used for this purpose. The 
most useful are phenol (carbolic acid), menthol, cam- 
phor, chloral, thymol, oil of cade, alcohol and alkalies. 
The following are a few prescriptions which are sug- 
gestive. Various modifications of any one of them 
may act satisfactorily. 

Gm. or C.c. 

1$ Phenolis 

Liquoris potassae aa 5 or A3 iss 

Petrolati liquidi q. s. ad 50 AS ii 

M. Sig. : Use externally as directed. 

Shake. 



DRUGS IN PRURITUS 



523 



Or 



U 



Gm. or C.c. 
. 3 



Phenolis , 

Glycerini 10 

Liquoris calcis 25 

Aquae q. s. ad 100 

M. Sig. : Sponge over irritated surfaces. 

Shake. 



fl3i 
fl3iii 
flSi 
flSiv 



Or, 



I£ Phenolis 

Zinci oxidi 

Amyli pulveris 

Calaminae aa. 

Glycerini 

Aquae q. s. ad. 

M. Sig. : Sponge over affected area. 



Gm. 


or 


C.c. 




1 







V\, XV 


20 
10 

180 









3v 

3 iss 
Svi 



Or: 



$ Mentholis 

Sodii bicarbonatis 15 

Glycerini 25 

Aquae q. s. ad. 250 

M. Sig. : Use externally as directed. 



Gm. or C.c. 
50 



or 



gr. vn 

5 ss 

fl3vi 

MS viii 



Or: 



3 



Mentholis 

Camphorae 1 

Olei amygdalae dulcis 2 

Adipis lanae hydrosi 25 

M. Sig. : Use externally. 



Gm. or C.c. 
50 



gr. x 
gr. xviii 

TTt xxxv 

Si 



Or: 

Gm. or C.c. 

Ifc Camphorae 

Chlorali hydrati aa 15| 

M. Sig. : Paint over affected part. 



5 ss 



Or 



fy Mentholis 

Thymolis 2 

Aquae 100 

M. Sig: Use externally. 



Gm. or C.c. 
1 



gr. xv 
gr. xxv 
AS iii 



524 DRUGS IN PRURITUS 

Or: 

Gm. or C.c. 

B Camphorae 5 

Zinci oxidi 15 or 

Cretae preparatae 30 

M. et fac chartulam 1. 

Sig. : Use as a dusting powder. 



gr. lxxv 
Sss 
Si 




Or: 

Gm. or C.c. 

$ Olei cadini 51 A3 iss 

Petrolati 50 1 or I ii 

M. Sig. : Use externally. 

Or: 

Gm. or C.c. 

B Olei cadini 51 A3 iss 

Adipis I or 

Adipis lanae hydrosi . ....aa 25 1 3i 

M. Sig. : Use externally. 

As a lotion the following antipruritic mixture will 
be found extremely soothing: 

Gm. or C.c. 
I£ Zinci oxidi 10 

Talci purificati 10 

Sodii boratis 10 

Mentholis 2 80 

Glycerini 10 

Aquae calcis q. s. ad. 200 

M. Sig.: External use. 
Shake. 

Or: 

Gm. or C.c. 

Ifc Tincturae iodi I 

Tincturae opii aa 51 or A3 iss 

Glycerini q. s. ad 25] A3 i 

M. Sig. : Paint on externally. 

The above prescriptions may be used when only a 
small part itches, as in chilblain, or something of that 
description. 

Various alcohol and menthol sprays and washes, or 
simple saline sprays are often satisfactory. The fol- 
lowing is a menthol spray : 



PRURITUS ANI 525 

Gm. or C.c. 

Ifc Mentholis 1 gr. xv 

Alcoholis 100 or flB iii 

Aquae q. s. ad 200 A3 vi 

M. Sig. : Use externally with an atomizer. 

The question of the use of alcohol and tobacco is 
usually raised in connection with the treatment of pru- 
ritus, and it is generally advised that both should be 
forbidden. Certainly, the vast proportion of people 
who use tobacco and alcohol are not affected with pru- 
ritus. This of course does not indicate that they may 
not be detrimental to sufferers from pruritus, and pos- 
sibly in some instances their use aggravates the condi- 
tion. In such cases their discontinuance should cer- 
tainly be advised ; but in most cases their use or disuse 
will probably be a matter of indifference. 

PRURITUS ANI 

While it is universally insisted that the term "pru- 
ritus" should be strictly limited to such itching affec- 
tions of the skin as are not accompanied by any recog- 
nizable lesion, the term "pruritus ani," on the other 
hand, is used much more broadly, so that under it are 
commonly included such affections about the anus as 
are accompanied by itching but do not show any mani- 
est lesion, and also those conditions in which there 
are decided pathologic changes in the skin and in which 
intense itching is the most important symptom. Pru- 
ritus ani commands the attention and interest of the 
general practitioner, the proctologist, the dermatologist, 
and, at times, the neurologist. 

ETIOLOGY 

The physician does not do his full duty to his 
patient, if he prescribes for itching about the anus with- 
out making a careful examination of that region and 
interrogating the patient in regard to his habits and 
the manner in which the functions of the different 
organs are performed. It is, ordinarily, a simple mat- 
ter to determine whether the itching is due to the 
presence of the Oxyuris vermicularis (pin- worm) or 
to the presence of pediculi. The occasional occurrence 
of these parasites in this region and their causative 



526 ETIOLOGY OF PRURITUS ANI 

relation to the production of itching should not be 
overlooked. On local examinations, it is frequently 
possible to detect the presence of a fissure of the anus, 
or an ulcer in that situation, or within the sphincter 
ani muscle. In other cases there may be found a fis- 
tula, hemorrhoids, or polypi; and further exploration 
of the rectum may show a catarrhal condition of the 
mucous membrane, or a disease of the crypts. 

At the beginning of the condition it may be impos- 
sible to find any lesion, but, as the case progresses unre- 
lieved, the energetic scratching in order to relieve the 
itching usually produces a thickening of the skin. 
Inflammation of the skin occurs, causing an increase of 
the connective tissue which presses on the nerve end- 
ings. This may be followed by an atrophic condition 
of the superficial layer of the skin. The thickened 
integument may have a whitish, sodden appearance, 
and may lie in folds, on or between which there may 
be fissures caused by the scratching. 

Many cases are accompanied by a condition of 
moisture of the skin about the anus. Some believe that 
this moisture is the cause of the itching, but it is more 
probable that in most cases it is an accompaniment of 
the condition that gives rise to the itching, or may 
accompany that lesion of the skin which is produced or 
aggravated by scratching. This moisture is probably 
due to a hypersecretion of the subaceous glands, but it 
is possible that a part of it comes also from the sweat 
glands. 

In some cases it will be found that a disturbance 
remote from the local manifestation gives rise to the 
itching. Congestion of the mucous membrane of the 
intestine accompanied by a catarrhal condition; con- 
gestion of the liver may be accompanied by a conges- 
tion about the anus which gives rise to intolerable 
itching. Pressure on the veins, as from the enlarged 
uterus during pregnancy, or from pelvic or abdominal 
tumors, may produce similar effects. 

Some general diseases are occasionally accompanied 
by pruritus ani. The most important of these is dia- 
betes, but the condition may be present in chronic 
nephritis, in gout, and in rheumatism. It is also a not 
infrequent accompaniment of the degenerative changes 



MANAGEMENT OF PRURITUS ANI 527 

which accompany old age. Some cases show a decided 
neurotic element. Sometimes business or professional 
men who are actively engaged in following their voca- 
tion and who are subject to unusual nervous and mental 
strain are the subjects of this disorder. These various 
conditions, which do not cover all the causes which 
have been enumerated as etiologic factors of this itch- 
ing, indicate that there is a wide scope for the use of 
judgment in selecting a line of treatment appropriate 
for each individual case. When this condition is an 
incident of senility, or of such general diseases as dia- 
betes or nephritis, the treatment is generally palliative, 
by means of local applications. Of course, any 
improvement in the diabetes, or in the nephritis, will 
cause improvement in the local trouble. 

MANAGEMENT 

The dietetic management of the case and the employ- 
ment of such remedies as promote excretion of the 
products of metabolism are clearly indicated. In a 
large number of patients it will be found that a 
rearrangement of the diet is of great importance. 
Many of these patients eat too much, and their diet 
should be restricted so that they eat less and limit the 
amount of food to the needs of the system. 

In many cases there is constipation, accompanied, 
sometimes, by intestinal fermentation. If this consti- 
pation cannot be corrected by a regulation of the diet, 
some laxative may be necessary. Aloes sometimes 
seems to do harm by increasing the irritability and 
congestion about the rectum. Usually cascara or a 
saline cathartic is preferable. Sometimes it is well to 
give a moderate dose of cascara at night and follow 
this by a saline laxative in the morning, regulating 
the dose so that the patient may have one soft move- 
ment after breakfast. 

If the urine is highly colored, of high specific grav- 
ity, or is strongly acid, the administration of alkalies 
such as potassium citrate is useful. 

Sometimes an operation, perhaps slight or not rarely 
of considerable gravity, is indicated. If there are 
tags of hypertrophied skin, they should be snipped off. 
If there are hemorrhoids they should be removed. If 



528 LOCAL TREATMENT OF PRURITUS ANI 

there is a fissure or ulcer, it must be treated by local 
application of solutions of nitrate of silver daily, if 
the solutions are weak (from 1 to 3 per cent.) ; once 
in four or five days, if strong (10 per cent). If there 
is a fistula, it should be incised or excised. If there 
is catarrh of the rectum, it may be treated by alkaline 
enemata. 

A considerable number of these patients have been 
treated with very gratifying results with the roentgen 
ray. These applications may be given at first with two 
exposures a week, until some dermatitis is produced, 
and then once a week. The roentgen ray causes a 
diminution of the excessive moisture which is some- 
times present, and a decrease in the size of the sebace- 
ous follicles, which seem to be affected by the ray 
more than the sweat glands. Others have used the 
high-frequency current with asserted advantage. 

LOCAL REMEDIES 

Various local remedies are used with more or less 
success. A group of suggestive prescriptions will be 
found above. 

Before thinking of applying any remedy, a most 
scrupulous cleanliness should be exercised. After 
every movement of the bowels, the anal region should 
be bathed with hot water, which may be used without 
medication, or there may be dissolved in it simple 
salt, borax, or bicarbonate of sodium. The use of 
newspaper or other coarse paper should be strictly 
prohibited. 

At such times as the itching comes on intensely, espe- 
cially in the evening or after retiring, local applications 
either ice-cold or very hot water often afford consid- 
erable relief. The hot water may be medicated by the 
addition of boric acid to the point of saturation, or 
with borax. Phenol (carbolic acid) may be applied 
in solution of from 2 to 3 per cent, strength, and it may 
be used in much stronger solution once or twice a 
week. 

Pusey and Sutton both recommend highly the use 
of the roentgen ray in intractable cases of pruritus ani, 
vulvae or scroti. It is applied in moderate dosage at 
daily or triweekly intervals. 



ETIOLOGY OF PRURITUS VULVAE 529 

PRURITUS VULVAE 

All of the general remarks applicable to pruritus 
ani and perineal pruritus are equally applicable to pru- 
ritus vulvae. 

An attack of vulvar pruritus accompanying some 
genital affection is liable to return later, even without 
any local factor to invite it. Drugs known to have 
brought on vulvar pruritus in local applications are 
salol, phenol, mercuric chlorid, and merely too hot 
and too often repeated water douches, perfumed soaps, 
toilet waters, etc. Still another and quite frequent 
cause is the oxyuris. With this there is usually associ- 
ated anal pruritus. The eggs of the oxyuris may be 
deposited on the mucosa or skin and cause pruritus. 
The lesions resemble those of a secondarily infected 
eczema, and only a mcroscopic examination will reveal 
the helminth's ova. Thrush has also been observed as 
a cause of pruritis in young infants and debilitated 
elderly women, and in a few pregnant women. A 
polyp in the urethra, urethritis, calculi in the bladder, 
herpes, zona, inflammatory processes in the vulva, 
vagina or uterus or fibromas are also liable to induce 
pruritis, as likewise diabetes and other constitutional 
diseases. 

The vulvar pruritus in pregnancy, usually disappears 
after delivery. The women subject to vulvar pruritus 
at the menopause may be of the gouty temperament 
or there may be local changes in the vagina setting up 
the pruritus or nervous disturbances. After exclusion 
of all other causes, there is left a group of cases with 
essential pruritus. It is distinguished by its intensity 
and tenacity. Tentative organotherapy is justified 
here, trying ovarian, thyroid and pituitary treatment. 
Vulvar pruritus thus requires general treatment to 
relieve constitutional disease, to reduce toxemia and 
reenforce the resisting powers in all ways, studying 
the inherited predisposition, the environment, the food, 
the general hygiene, and traumatism. Among the 
measures that may be required are change of scene, 
and abstention from coffee, tea, chocolate, sausages, 
veal, fish and shellfish, cheese, tomatoes, spices, straw- 
berries and gooseberries, cabbage and cauliflower. 
Hygiene of the digestive tract ranks first in all treat- 



530 SCABIES 

ment of pruritus. The teeth should be kept in order; 
a decayed tooth may keep up a pruritus started by 
some other cause. 

In one-sided, unaccountable and unexplainable 
pruritus, the Roentgen ray has effected a cure. 

SCABIES 

If the burrows and the itch mite are found, of course 
the diagnosis of scabies is readily made, but there are 
many cases of itch in which the burrows are difficult 
of discovery, and the itch mite is elusive and evades the 
dermal scrapings for microscopic examination. Even 
the itching varies with different individuals, some few 
being very tolerant of the irritation and thus becom- 
ing conveyors and transmitters of the disease without 
their personal knowledge. 

Various types of skin irritation develop during the 
several stages of scabitic inflammation. There may be 
papules, vesicules, pustules and crusts. The severest 
itching is generally present at night, and especially on 
first retiring. 

"The burrow or run is made by the female in the 
lower layers of the cornified epithelium of the skin." 
These burrows, or "roughened, curved furrows," occur 
most frequently on the anterior surfaces of the wrists 
and between the fingers. Sometimes these burrows are 
simulated by dirt-filled lines in the epidermis. The 
diagnosis can generally then be made by shaving off the 
suspected epidermis with a scalpel, then laying the 
epithelial slice on a slide, adding a drop of glycerin, 
placing a cover glass over it and examining with a, 
low power lens. If the eggs of the itch mite, or the 
mite itself, are found, the diagnosis is established. 

When the fingers and hands do not show signs of 
this infection, signs may be discovered on the elbow 
tips, and on the nipples of women. When there is a 
generalization of the disease, characteristic signs and 
eruptions will be seen on the hands, wrists, axilliary 
folds, abdomen, nates, in the popliteal spaces, and more 
or less on the genitals. 

It should not be forgotten that the itch may be pres- 
ent in a mixed infection ; in other words, there is more 
or less eczema from the irritations and scratchings, 



I 



TREATMENT OF SCABIES 531 

there may be nodular and suppurative processes, 
enlarged glands and syphilitic eruptions. 

The disease does not seem to be acquired in ordinary 
social life, but is caught mostly in bed, from individual 
to individual, or by sleeping in an infested bed. 

TREATMENT 

The parasiticides most used in eradicating the itch 
are sulphur, betanaphthol, balsam of Peru and cresol. 

The patient should be instructed to take. a hot bath, 
using plenty of soap and thoroughly cleansing, perhaps 
with a soft nail brush, the parts where the parasites are 
mostly located. He should then anoint all parts of his 
body with the sulphur ointment, and should especially 
rub it into the parts most affected. 

In mild cases of this disease thorough bathing and 
cleansing of the affected parts with strong alkaline 
soap, rubbing and dusting the rest of the body with 
washed sulphur, and then dusting the sheets of the 
bed with this dry sulphur, may cause an eradication of 
the disease without the necessity, discomfort and nasti- 
ness of ointments. 

In more severe cases, sulphur is commonly employed 
as an ointment, 1 to 2 drams to the ounce, thoroughly 
rubbed in over the affected parts, the head alone being 
excepted. The ointment is well rubbed in at night, the 
patient then donning a suit of woolen underwear which 
is not changed for from three to five nights, the dura- 
tion of the treatment. Each night a new supply of 
ointment is rubbed in. At the end of the treatment 
the patient may bathe; but no bath need be taken 
between treatments. 

SULPHUR 

The official sulphur ointment contains 15 per cent, 
of sulphur, and is stronger than should generally be 
used, on account of the irritation and actual dermatitis 
that it may cause. Either one of the following may be 
p/ef erable : 

Gm. or C.c. 

Ifc Sulphuris loti 101 or 3 iss 

Adipis benzoinati q. s. ad 100| B iii 

M. Sig. : Use externally, as directed. 



532 RINGWORM 

Or: 

Gm. or C.c. 

Ifc Unguenti sulphuris | 

Adipis benzoinati aa 50| or 3 iss 

M. Sig. : Use externally, as directed. 

Or in severe case : 

Gm. or C.c. 
IJ Betanaphthol 1 

Balsami peruvianae 2 

Unguenti sulphuris 30 

M. Sig. : Use externally, as directed. 

Or for use especially in children : 

Gm. or C.c. 



Sulphuris sublimatis 

Balsami peruvianae aa 2 

Adipis 30 



3ss 
Si 



RINGWORM: TINEA TRICHOPHYTINA 

To two very different diseases the name "tinea" has 
been given: one is tinea favosa, which is caused by 
the Achorion schbnleinii, the other is tinea trichophy- 
tina, which is caused by the vegetable parasitic fungus 
trichophyton. It is the latter to which the present 
remarks will be limited. 

The effects of this fungus are usually divided into 
three subdivisions, according to the particular part of 
the body affected. When that part of the face on 
which the beard grows is affected, it is distinguished 
as tinea barbae, or ringworm of the beard, or barber's 
itch. When the hair of the scalp is affected, it is known 
as tinea tonsurans, or ringworm of the scalp. When 
other parts of the body are affected it is known as 
tinea circinata, or ringworm of the body. These three 
varieties of the disease are also distinguished respec- 
tively as tinea trichophytina barbae, tinea trichophy- 
tina capitis, and tinea trichophytina corporis. The 
same remedies are applicable to the treatment of these 
three forms of the disease, but the location in which 
the lesion is found necessitates some difference in their 
mode of application. 

The trichophyton fungus is found and grows in the 
epidermal layer of the skin. It penetrates into the 
hair follicles, and also into the root and body of the 



TREATMENT OF RINGWORM . 533 

hair. Its presence in the latter locations renders the 
application of drugs for its destruction very difficult, 
and it is on this account that the affection of the hairy 
scalp and the beard is especially resistant to treatment. 

There are several drugs which are useful in the 
treatment of the disease when they can be effectively 
applied. The most important are mercury, iodin, resor- 
cin and chrysarobin. When there are a few spots on 
the surface of the body, a useful application is the fol- 
lowing : 

Gm. or C.c. 

R. Hydrargyri chloridi corrosivi 110 gr. ii 

Glycerini 51 or 3 ii 

Aquae q. s. ad 50] A3 ii 

M. Sig. : Shake, and rub thoroughly into the lesion, twice 
a day. 

The application of this lotion, or in fact of any 
remedy, should be preceded by a thorough scrubbing 
of the affected parts with hot water and soap, prefer- 
ably soft soap or green soap. When the patient is 
a young child, care should be exercised not to apply too 
strong a lotion and not to apply it to too extensive a 
portion of the body, for too liberal applications of 
strong mercurial lotions may cause mercurial poison- 
ing. 

If one prefers to use an ointment — and ointments 
are often exceedingly useful because watery prepara- 
tions do not easily penetrate the skin — an efficient 
ointment is the official unguentum hydrargyri ammo- 
niati. This ointment is 10 per cent, in strength. If 
there are many spots of disease, or the skin is tender, 
it is well to dilute it with an equal part of lard or 
petroleum fat. as: 

Gm. or C.c. 

B Unguenti hydrargyri ammoniati | or 3 ss 

Adipis benzoinati aa 15 1 

M. Sig. : Apply to spots twice a day. 

If the condition is chronic, and these washes and 
lotions do not prove effective, the patches may be 
painted with tincture of iodin. This may be repeated 
every day for several days until the inflammation 
becomes so great that the application causes objection- 
able discomfort. 



534 ROENTGEN RAY IN RINGWORM 

Ointments containing chrysarobin or pyrogallol are 
effective, but should not often be used on account of 
the fact that they stain the skin and clothing, and some- 
times cause considerable inflammation. 

In a series of cases successfully treated by Ormsby 
and Mitchell, the treatment consisted of three prepara- 
tions. In the severe pyodermic or eczematoid-derma- 
titis cases, a preliminary soothing treatment of naf talan 
combined with zinc oxid and starch was used. This 
was followed by 5 per cent, chrysarobin in traumaticin 
(chloroform solution of gutta percha) which was 
painted on until a good reaction occured. Ordinarily, 
the chrysarobin in traumaticin was immediately pre- 
scribed and direction given for five daily applications. 
The patient was asked to return for observations after 
eight days. If necessary, the treatment was repeated. 
In another series of cases, an ointment recommended 
by Whitfield was used. This contains 2 parts of sali- 
cylic acid and 4 parts of benzoic acid in 30 parts of 
ointment base. It is applied daily and can be used 
for several weeks without producing irritation. 

Chrysarobin was used alone in thirty-six patients, 
who made an average number of 3.6 visits. The oint- 
ment mentioned above was used alone in eight patients, 
who made an average number of two visits. The 
number of cases in which the ointment was used is 
obviously much too small for comparison, but it 
appears to be somewhat more efficient than chrys- 
arobin. Pusey has recommended the application of 
iodin, 2 per cent., in tincture of benzoin and Sequeira 
has recommended a mixture of 1 dram (4 grams) of 
resorcin to 1 ounce of the compound tincture of 
benzoin. 

The roentgen ray has been used as a germicidal 
application, and as a promoter of a mild dermatitis 
(ofter a forerunner of a cure) in all parts of the body, 
and with frequent reports of success. The hair, when 
the ray is used on hairy parts, falls out, but seems to 
generally soon return. Such treatments are best admin- 
istered by an experienced roentgen-ray therapeutist. 

Foley (Lancet, Jan. 24, 1914) describes the follow- 
ing method which he believes is extremely effective: 
the diseased area is first washed with a strong solu- 



OINTMENTS IN RINGWORM 535 

tion of sodium bicarbonate and swabbed with spirit 
of ether to remove grease. It is then painted with 
tincture of iodin and sprayed immediately with ethyl 
chlorid until the integument gets china white. The 
deeper the disease process the longer the spray must 
be applied. In ringworm of the scalp three or four 
applications may be necessary, but on smooth surfaces 
one application usually suffices. 

Hartzell has also found the ointment suggested by 
Whitfield, which contain 3 per cent, of salicylic acid 
with 5 per cent, of benzoic acid, most effective ; but, he 
says, it cannot be used, as Whitfield has pointed out, 
without some degree of caution in markedly inflam- 
matory cases, as it occasionally produces considerable 
irritation. The formula for this ointment is : 



Gm. or C.c. 

Benzoic acid 2 

Salicylic acid 1 

Linseed oil 15 

Lanolin 15 



gr. xxx 

5 gr. xxiv 

aa§ ss 



These cases are often very obstinate, and treatment 
must sometimes be carried on intermittently, for 
weeks. It often happens that an apparent cure results 
while a few of the fungi still remain in the skin with- 
out showing any evidence of their presence. Conse- 
quently, cases should be kept under observation for 
some time after cure is apparently complete, and if any 
evidence of a return of the disease appears, the treat- 
ment should be renewed. 

This disease appears more frequently in children 
than in adults, and the growth of the fungus seems to 
be favored by high temperature and by moisture. The 
disease is contagious, and is readily passed from one 
individual to another. Where considerable numbers 
of people associate intimately together great care 
should be observed to prevent one contracting the dis- 
ease from another. The use of combs, brushes, towels 
and clothing by different individuals should be strictly 
forbidden, especially when the existence of a single 
case among a number of children, as for instance in a 
large family or in a school, is known. It seems likely 
that with the extension of medical inspection to chil- 



536 TINEA TONSURANS 

dren in the public schools and with sanitary barber 
shops, this disease will, in a few years, become exceed- 
ingly rare. 

TINEA TONSURANS 

Ringworm of the scalp or bearded portions of the 
body is ordinarily a stubborn condition to treat. There 
are two chief methods used in the treatment — the 
drug treatment and the roentgen ray. 

The roentgen-ray treatment is of material aid in 
shortening the course of the disease. It produces 
epilation ; it does not seem to kill the fungi but it may 
stimulate the skin to a healthy inflammatory process 
that aids in ridding it of the organisms. Such treat- 
ments should not, however, be undertaken by those not 
thoroughly conversant with the action of roentgen 
rays, as the harm done by incautious use of the appa- 
ratus may be irremediable. 

The local use of remedies rarely effects a cure of 
this stubborn condition. The remedies suggested are 
usually strong antiseptics. The same preparations 
recommended for ringworm of the body may be 
utilized. The hair should be cut very short, thoroughly 
scrubbed and the remedy applied vigorously. Severe 
cases are best treated by the specialist. 

TINEA CRURIS 

This is a disease that frequently attacks in epi- 
demic form the students of universities and prepara- 
tory schools. It occurs on the inner side of the thighs 
near the body, often spreading to the scrotum, to the 
abdomen, to the perineum, and to the buttocks. The 
hairs do not fall out, thus differing from the ringworm 
that attacks the scalp and other parts of the body. 
There is slight itching and burning, but the disease 
may go on for weeks and even months without very 
much disturbance to the patient. The most frequent 
organism is the Epidermophyton inguinale. It does 
not tend to recovery and will persist until properly 
treated. In fact, the treatments outlined in most of 
the books on skin diseases are tediously ineffectual, and 
the statement is often made that a cure of the disease 
requires weeks and even months of treatment. Con- 



TINEA CRURIS 537 

sequently ordinary treatments of this disease are 
usually unsatisfactory. 

The following treatment is one which has been found 
effectual and curative in a short space of time. It 
has been successful where some of the milder antiseptic 
treatments have failed. It must be impressed on the 
patient that reinfection readily and almost persistently 
occurs unless the greatest cleanliness of the under- 
clothing and even trousers is inaugurated. It is evi- 
dently transmitted from patient to patient from the 
closet seats. Dirty jock straps and suspensory band- 
ages used in athletics are persistent transmitters of 
the disease. Therefore, clean clothing must be worn 
after all the washable clothing has been boiled and the 
trousers have been properly cleaned and properly 
ironed. Closets must be rendered aseptic by frequent 
corrosive sublimate baths. 

TREATMENT 

The patient should be instructed to come to the 
office, bringing clean drawers and a clean shirt, so that 
after the antiseptic treatment he can put on clothing 
that is not infected. The different steps in the anti- 
septic process are : 

1. The parts are all thoroughly cleansed with a soft 
brush or cotton, and liquid soap, and the skin for four 
or five inches distance from the infected areas should 
also be cleansed with this soap. The scrubbing should 
not be very severe, as the skin must not be broken and 
the epidermis not too severely removed. 

2. The infected area should then be wiped over 
thoroughly with a 2.5 per cent, phenol solution. This 
will slightly anesthetize the parts to which the stronger 
antiseptic must be applied. 

3. A cotton swab is now wet with the official for- 
maldehyd solution. This is then lightly swabbed over 
all the infected parts, which are kept wet for three min- 
utes, provided the patient can stand the burning pain 
for this length of time. If there is an area that is 
especially red and inflamed and sensitive, this part may 
be swabbed with the next solution mentioned before 
the three minutes have elapsed. 



538 IMPETIGO CONTAGIOSA 

4. The whole area to which the formaldehyd solu- 
tion has been applied is now thoroughly washed with 
the 2.5 per cent, phenol solution. This quickly relieves 
the pain caused by the formaldehyd application. 

5. After the burning pain has ceased, the skin is 
gently dried and talcum powder is dusted over it. The 
patient then dresses in his clean clothing and takes 
care that he does not come in contact with any infected 
garments, beds or closets. 

6. After twenty-four hours the patient should report 
for observation. If severe irritation has been caused 
by the formaldehyd solution, a 2 per cent, phenol oint- 
ment should be applied. If there is not severe irrita- 
tion or inflammation, the simple talcum dusting powder 
is to be freely used. 

7. At the end of a week the patient is again exam- 
ined, and if there are any recurrent small areas, which 
may happen at the margins of the affected region, these 
are again touched with the formaldehyd solution. 

By the above treatment a cure may be expected 
immediately and certainly within two weeks. The 
success of the antiseptic treatment is certainly far in 
advance of the ordinary treatments of this inveterate 
disease. 

The preparations advised are as follows : 

Gm. or C.c. 

R Phenolis liquefacti 2| 

Aquae q. s. ad 100| 

M. Sig. : 2 per cent, carbolic acid solution. 

Gm. or C.c. 

Ifc Liquoris formaldehydi 100| or A3 iv 

M. Sig. : Official formaldehyd solution. 

Gm. or C.c. 

1$ Phenolis liquefacti 150 or n\,x 

Petrolati 25] Si 

M. Sig. : Apply externally as directed. 

IMPETIGO CONTAGIOSA 

Pus infection of the skin, usually of the staphylo- 
coccic type, is an exceedingly troublesome condition. 
Crusts should be removed by the application of moist 
dressings, bathing with warm water, or mild friction 



IMPETIGO CONTAGIOSA 539 

with gauze. In young children, scratching should be 
prevented by the application of bandages or suitable 
splints to prevent bending the elbows. Ammoniated 
mercury ointment is usually recommended for this 
condition. The official ointment contains 10 parts of 
white precipitate in 90 parts of benzoinated lard. Sut- 
ton has stated that this preparation is too strong for 
the most effective use and he finds an oily preparation 
better than a fatty preparation, viz. : 

Gm. or C.c. 

Ifc Hydrargyri ammoniati 11 or gr. xv 

Olei olivae 100| A3 iv 

M. Sig. : Apply externally as directed. 

If deemed advisable, compresses may be soaked in 
this solution and kept in place over the affected areas 
by means of bandages or adhesive plaster. In the 
hairy parts of the body, as in the beard, a continuous 
application for twenty-four hours of the above solu- 
tion will loosen all crusts and allow the antiseptic to 
reach the germs of infection and will inhibit the spread- 
ing of the disease. 

Morrow (Jour. A. M. A., July 21, 1917, p. 176) 
treats the areas underlying the crusts by painting with 
20 per cent, silver nitrate solution. This, he points out, 
has the two disadvantages of some painfulness and 
staining of the skin, but because of the reliability of the 
method he believes the objections may be disregarded. 

New lesions can usually be prevented by washing 
with boric acid solution, or with a weak solution of 
mercuric chlorid. Still, the patient should always be 
examined carefully and often, in order that new 
lesions may be recognized in their first stages and 
promptly aborted. A dusting powder, preferably one 
containing ammoniated mercury in the strength of 
from 6 to 10 per cent., and boric acid powder up to 
from 15 to 20 per cent., is applied following the silver. 
When the impetigo is on the uncovered part, even 
without the silver the powder form of treatment may 
be selected in preference to a grease. Adults who have 
the infection on the face should not shave until all 
active signs of it have disappeared and they should 
not subject themselves to the irritation of the wind, 
such as results from motoring in open cars. 



540 PSORIASIS 

Unna (Berl. Klin. Wchnschr., 1915, Hi, p. 453) 
says: "No true pus coccus affection of the skin, no 
isolated furuncle, no felon, should be taken lightly. 
When any of these have lasted any time, true pus cocci 
are already installed in the neighboring apparently 
sound hair follicles, ready to .start new impetigo or 
furuncles. They must be walled off from the rest of 
the skin with a rampart of coccus-destroying sub- 
stances. " For this he uses ichthyol, or an ichthyol or 
mercury-phenol plaster, or a zinc-sulphur-chalk-tur- 
pentine paste. Another formula contains 10 parts 
sulphur lotum, 10 parts calcium carbonate and 80 parts 
zinc ointment. 

Before applying any of these preparations he washes 
the lesions and after drying touches them lightly with 
concentrated phenol on the suppurating points and 
also the roots of the hair around the spot. In case of 
extensive pyodermia, all the pustules are opened and 
the entire body is rubbed long and thoroughly with 
soap. He states any soap will do except tar soap, 
which, he thinks, breeds folliculitis. All the pustules, 
then, and their environment, are covered with zinc 
paste and gauze as maceration of the skin from friction 
of any kind promotes spreading of the impetigo. 

PSORIASIS 

The cause of psoriasis has been variously attributed 
to an infectious nature, to errors in metabolism, to dis- 
ease of the glands of internal secretion. An inherited 
tendency seems evident in 5 or 6 per cent, of the cases, 
and anything causing internal disturbances is liable 
to aggravate the condition or bring on attacks, espe- 
cially digestive disturbances, abuse of coffee, tobacco 
or alcohol, a diet too rich in albumin, or constitutional 
disease. When diabetes and glycosuria can be 
excluded, benefit is often derived from a vegetarian 
diet. It is doubtful if any of the theories as to the 
cause of psoriasis is supported by conclusive evidence. 

TREATMENT 

In treating psoriasis, various new methods have 
been proposed and tried more or less in the last few 
years, but none of them has proved of great value. In 
general, chrysarobin ointment still remains the most 



TREATMENT OF PSORIASIS 541 

effective remedy for cleaning up psoriasis. The cus- 
tom today is to use it in rather dilute strengths — from 
2 to 5 per cent, chrysarobin in some ointment base. 
The lesions can often be cleaned up with Roentgen 
rays, but the method is not to be recommended unless 
used with great caution. As a rule, the eruption 
recurs after Roentgen-ray treatment, as after all other 
methods of treatment. Another recent method of 
treatment is exposure to highly actinic rays of light. 
Sometimes ordinary sunburning will clear up psoriasis, 
and exposure to ultraviolet light may do the same 
thing; but as a rule this method of treatment is dis- 
appointing. Autoserotherapy is another method sug- 
gested, but it has not yet been proved of value. The 
same can be said of the treatment of psoriasis with 
vaccines. Seek and remove focal infections. 

ARSENIC 

In chronic cases when the disease has passed the 
stage of acute hyperemia, arsenic may be given in the 
form of Fowler's solution, three to ten minims, three 
times a day or as arsenous acid, in pills. 

Arsenic should not be given when the eruption is 
active and increasing. When it has been given to full 
physiologic effect, as evidenced by pain in the stomach, 
nausea, vomiting, diarrhea, pufrmess or redness of the 
eyes, albumin or blood in the urine, it should be 
stopped for several days. 

The salicylates, alkalies and diuretics have also been 
recommended for internal use in psoriasis in some 
cases, also thyroid and iodid of potassium have seemed 
in some cases to yield good results. 

LOCAL TREATMENT 

The scales may be removed by scraping with a sharp 
curet and washing with hot water and green soap, or 
in hot baths containing 4 grams of sodium bicarbonate 
to each gallon of water. A stiff brush may be used. 
If the scales are hard and there is thickening a 5 per 
cent, salicylic acid ointment will aid in softening and 
removing them. 



542 CHRYSAROBIN IN PSORIASIS 

Chrysarobin is the remedy of chief reliance in 
removing the patches. It may be applied in the fol- 
lowing manner: 

Gm. or C.c. 
3 Chrysarobini 1 1 or gr. xv 

Liquoris guttae perchae(N.F.) 10| 3 iii 

M.Sig. : Apply at night, with a camel's hair brush. 

Gm. or C.c. 
B Chrysarobini 31 3 i 

Aetheris or 

Alcoholis q. s. ad solutionem 

Collodii 25 1 Si 

M. Sig. : Apply at night with a camel's hair brush. 

Chysarobin should not be used on the face and it 
should be remembered that the stains which it makes 
on clothing cannot be removed. 

An ointment containing chrysarobin and salicylic acid 
(Dreuw's ointment) may be used over small areas on 
severely indurated lesions. The formula is : 

Gm. or C.c. 

fy Acidi salicylici 10! 3 iii 

Chrysarobini 

Olei rusci aa 20| or 3 vi 

(Oil of Birchwood) 

Saponis mollis 

Petrolati aa 25 f 5i 

M. Sig. : "Rub in well, with a stiff brush, for five evenings. 
Then take hot baths on three successive evenings, using appli- 
cations, of olive oil in the meantime (to soften the skin). 
Repeat if necessary." 

Chrysarobin may also be employed in a guttapercha 
paint like traumaticin. 

"When there are patches of psoriasis on the face or 
scalp only the white precipitate ointment should be 
used, as the chysarobin is likely to give rise to severe 
erythema and edema in these regions." 

It is best not to persist too long with any one remedy. 
Ammoniated mercury ointment, 5 to 10 per cent., may 
be of value, and ichthyol, tar, sulphur and beta- 
naphthol have likewise formed the chief ingredients 
of curative ointments. 

DIET 

Many patients with psoriasis are greatly benefited 
by a vegetarian diet. The intake of all nitrogenous 



I 



BOILS AND CARBUNCLES 543 

foods should be limited. Alcohol, highly seasoned 
food, salted meats, pastry and sweets should be for- 
bidden. 

BOILS AND CARBUNCLES 

These frequent and unwelcome visitors are always 
due to an infection. The greatest preventive is con- 
stant cleanliness of the back of the neck, the axillae, 
and the gluteal, perineal and genital regions, which are 
the parts most frequently affected with boils. The 
back of the neck is the most frequent place, in men, 
for boils and carbuncles to occur. Infection readily 
occurs in the hair of the lower part of the occiput 
and upper neck region. 

A boil having occurred, contiguous hair follicles 
may become infected, or more distant parts of the 
body may develop one or more boils. Doubtless such 
isolated boils are frequently caused by direct trans- 
mission by scratching with contaminated ringers. Fre- 
quently boils occur from infection transmitted by way 
of the blood or lymphatics from some focus of sup- 
puration; or a boil may infect the blood and cause 
crops of boils and repeated attacks after periods of 
remission. Repeated crops of boils may occur from 
foci of infection in the nose, nasal sinuses, tonsils, 
teeth and gums ; they are not as likely to occur from a 
suppurating ear, from a fistula, or walled-off sinus, 
but it cannot be too frequently reiterated that foci of 
infection in the nose and mouth are a menace. Dia- 
betes particularly predisposes to boils. 

ETIOLOGY 

A furuncle, or boil, is an inflammation of the deeper 
layers of the skin and adjacent subcutaneous tissue, 
generally circumscribed about a hair follicle or sebace- 
ous gland. The Staphylococcus pyogenes-aureus seems 
to be the most frequent germ of infection. The 
intruder, of course, rapidly propagates his species, irri- 
tation takes place, the blood vessels of the region 
become dilated, leukocytes hasten to the defense of the 
patient, and tumefaction, heat, and pain develop. The 
afflicted area becomes distinctly circumscribed, and, if 
not maltreated, may keep the infection within the 
bounds of the circumscription, with — if many lym- 



544 TREATMENT OF BOILS 

phatics are in the region — a rather rapid congestion 
of the adjacent glands. These also become secondary 
defenses against infection of the body. The pressure 
of the part increases, circulation in its center is inter- 
fered with, and the central part or core of the inflamed 
region becomes necrosed, soon softens, and breaks 
through the skin, and more or less thin pus, with blood, 
escapes. This generally occurs in about a week. Soon 
after this the central dead tissue becomes loosened 
from the healthy surrounding tissue and is easily 
removed or evacuated. The cavity then granulates 
and rapidly heals. 

TREATMENT 

If a boil is first seen when it is only a slight nodule 
with a punctate white speck on the skin, it has long 
been considered that abortive treatment is advisable, 
and that most recommended has been to puncture 
through this white or red point on the skin into the 
hard tissue with a toothpick or wooden applicator, 
which has been dipped in liquid phenol (carbolic acid). 
Or, with a hypodermic needle, a drop or two of phenol 
has been injected directly into the center of the hard- 
ened part. However, although many times successful, 
the majority of boils cannot be so aborted, possibly 
because they are rarely seen at this early stage. 

When a boil is first seen well on its way, incision 
before liquefaction and suppuration should be con- 
sidered, although sometimes it does not hasten the 
process and may increase the pain. 

The surrounding tissue of a boil should always be 
kept carefully cleansed with some mild antiseptic wash, 
as one of the liquid soaps, or even cleansed with a 
little ether. Then a wet dressing may be applied, best 
with some alkaline wash. Gauze saturated with such 
a solution and placed over the part, and a piece of oil 
silk over it, should be gently strapped or bandaged on. 
The gauze should be kept constantly moist with warm 
water. If the skin tends to become red and irritated 
about the boil, it should be soothed with petrolatum 
or with a dilute glycerin. No strong antiseptics should 
be used, any more than momentarily, on the skin. 



TREATMENT OF CARBUNCLES 545 

Mercuric bichlorid dressings, so long used and so 
much overused, are bad treatment for the skin in these 
cases. 

If the part around the boil is hairy, it should be 
gently and carefully shaved or closely clipped, and 
when the skin is perfectly dry, iodin may be painted 
once around the part; then proper simple cleanliness 
will prevent later infection of the hair follicles. 

As soon as the boil is opened, or it has come so 
near the skin that it is best to incise the outer layer 
of skin J:o evacuate the pus, it should be dressed fre- 
quently. Besides the cleansing of the skin about the 
part with alkaline washes, an ointment, as sterile 
petrolatum, may be spread around on the healthy skin 
to prevent the more or less irritant excretions from 
the boil causing irritation to healthy parts. The wet 
alkaline poultices should be continued as long as there 
is a hard, inflammatory area. As soon as this indura- 
tion has greatly diminished, the poultice part of the 
wet dressing should be stopped, that is, the oil silk, 
rubber tissue, or waxed paper should be omitted from 
the dressing, and simply the moist gauze placed over 
the boil. This wet dressing should be frequently 
changed, so that no pus is dammed back into the boil 
and free exit is constantly possible. This means that 
the dressing should be done at least twice in twenty- 
four hours, and better, three times. 

At each dressing, little pieces of dried pus or tissue 
should be gently removed with forceps, and just 
enough pressure brought to bear to bring the particles 
of dead tissue within reach of the forceps ; no squeez- 
ing should be allowed. 

" CARBUNCLES 

It is practically impossible to determine in most 
instances that a patient has a carbuncle. An apparent 
boil is likely to develop into several boils, with several 
openings, and becomes a carbuncle. Carbuncles are 
more likely to occur in men, and in older men than in 
young men, and more frequently on the back of the 
neck than on any other part of the body. However, 
wherever a carbuncle is located, on account of the 



546 BOILS AND CARBUNCLES 

large amount of tissue involved, there is always more 
or less danger from a phlebitis with thrombosis and 
possible direct infection of some large blood vessel. 

It is necessary that such a multiple infection as a 
carbuncle should have free opening for evacuation as 
soon as suppuration occurs. It may be even advisable 
for a surgical decision as to whether or not radical 
excision is advisable to prevent the constant danger of 
infection in one of the large veins of the head. Car- 
buncles on the upper lip or near the nose are very 
dangerous. 

It should be remembered that it is always possible 
for a boil or carbuncle to produce septicemia, and 
even a serious septic process of deeper structures of 
the body or of bones. In other words, while the indi- 
vidual boil is being treated, every possible focus of 
infection must be sought, and if one is found, means 
must be taken to eradicate it. A history of repeated 
boils and pustulations indicates a focus somewhere 
and, if it is not in direct evidence, all crowned and 
bridged teeth are under suspicion until the roentgen 
ray has proved them innocent. 

GENERAL TREATMENT 

As to general treatment, anything that makes for 
appetite, good digestion, proper movement of the 
bowels, and nutrition works for a successful fight 
against furunculosis. One of the recommended treat- 
ments is yeast. The ordinary compressed yeast cake 
is easily obtained and administered. The proper dose 
is about one third of a yeast cake, dissolved in a glass 
of water, twice a day. This" makes a sour drink, and 
is not disagreeable to most persons. If it causes the 
bowels to become loose, the amount should be dimin- 
ished. Yeast may have a beneficial action in gastro- 
intestinal sluggishness, and apparently has power to 
change the flora of the intestine. 

Sulphuric acid has been recommended in furuncu- 
losis, and sulphur is an old-fashioned treatment. If 
the patient is anemic, iron in some form should be 
given. 



ALOPECIA 547 

When there are multiple small spots of infection on 
the body, the underclothing should be frequently 
changed, and warm baths should be taken to prevent 
reinfection. 

Stock vaccines, and more frequently autogenous 
vaccines, have occasionally been found valuable. On 
the other hand, sometimes vaccines fail utterly to pre- 
vent the recurrence of boils. 

ALOPECIA: BALDNESS 

Several different forms of this condition have been 
described, of which the following are the types: 

Alopecia congenitalia is an exceedingly rare condi- 
tion in which a child is born without any hair. Micro- 
scopic examination of the skin in some cases shows an 
entire absence of follicles. In other cases the follicles 
are present, and after weeks, months, or possibly two 
or three years, the hair grows, although it is usually 
finer and thinner than in the average child of the 
same age. 

Another variety is alopecia senilis, in which the loss 
of hair is an accompaniment and an indication of the 
general atrophy of the tissues throughout the entire 
body. 

There is the disease called alopecia areata, which is 
characterized by a complete falling of hair from limited 
areas of the scalp or other hairy portion of the body. 
This is a distinct disease, and will not be considered in 
this connection. 

There remains the form of alopecia prematura, in 
which the patient loses more or less hair, but in which 
this loss is not associated with the changes character- 
istic of old age. This form, of premature baldness is 
customarily divided into two classes : the idiopathic and 
symptomatic. In the idiopathic form few causes can be 
found for the Occurrence, while in the symptomatic 
form there will be found some pathologic condition of 
the scalp, or some disease which has affected the gen- 
eral nutrition of the entire body. Under the latter 
head may be included the falling of the hair which so 
frequently follows typhoid fever. 



548 CAUSES OF BALDNESS 

Omitting at the present time a discussion of the other 
forms of alopecia, a few words will be said regarding 
the common form of premature alopecia. 

The most that can be said of premature baldness, 
according to Pusey, is that it is senile baldness coming 
on before the usual time. Of its causes we know 
actually nothing. We do, however, know the sequence 
of events. 

Between the skin of the scalp and the skull there is a 
thick layer of fat to which the skin is loosely attached 
and on which it is freely movable. In civilized man, 
who lives in houses and wears hats, the following 
changes take place as he approaches later life : This fat 
layer gets thinner; the scalp becomes more firmly 
attached to the skull and less movable; the skin 
becomes more tense, and with these changes the hair 
becomes thinner and thinner over the top of the head. 
Finally, in extreme cases, the hair disappears and there 
is left a bald, glistening crown closely drawn over the 
skull. This sad picture is senile, spontaneous or sim- 
ple baldness. Premature baldness is the same thing, 
only occurring before the age when these changes, 
which we ordinarily attribute to old age, are expected 
to appear. 

What is the process that has taken place? There 
has been a disappearance in great part of the sub- 
cutaneous fat; the scalp has become much more 
dense in structure — has become fibrous or sclerotic 
— and with this shrinking in the scalp there has been 
a "gradual shrinking in the hair follicles until they 
entirely disappear, and are replaced by fibrous tissue. 
It is a process much like that taking place in many of 
the tissues in later life, and in some of the organs, often 
as a result of disease. It resembles closely, for exam- 
ple, the destruction of the epithelial tubules in the kid- 
neys that takes place as a result of chronic inflamma- 
tory processes. And it is a process that can readily be 
explained as a result of a chronic inflammatory process 
in the scalp. This is a reason for one view that all 
socalled senile baldness is really due to dandruff or 
seborrheic dermatitis. The sounder view seems to be 
that the change may be simply one of senile atrophy 
occuring as a primary process and not secondary to 
any diseased condition of the scalp. 



CAUSES OF BALDNESS 549 

The explanation of the fact that baldness is usually 
confined to the top of the head probably is that the 
increased tension of the scalp resulting from its shrink- 
age exerts its chief pressure on the top of the head. If 
one pulled a bag tightly down over the head it would 
exert much more pressure on the top of the head than 
around the border. 

Simple or senile baldness, in spite of its name, usually 
begins to manifest itself early. The thinning of the 
hair becomes apparent before the age of 30 in 80 per 
cent of the cases, and persons who are not nearly bald 
at 50 are likely to keep a passable covering of hair 
until they reach old age. 

The definite causes of simple baldness are uncertain, 
and there is much room for speculation. As a result, 
all sorts of factors are invoked to explain it, from the 
wearing of tight hats to improper methods of breath- 
ing. Some would go so far as to say that there is no 
such thing and to attribute all of the cases to seborrheic 
dermatitis. This is an extreme view ; but certainly the 
ravages of dandruff have to be taken into account in 
all cases of baldness, and in considering the causes of 
the condition no separation can be made between sim- 
ple baldness and that due to dandruff. 

Baldness is much commoner in men than in women. 
This is true, however, only of complete baldness ; 
thinning of the hair is commoner, perhaps, in 
women than in men. The reasons for the occur- 
rence of baldness less frequently in women than in 
men are probably various. In the first place, women 
give much more attention to the toilet of the hair — 
to brushing it, and keeping it clean and in good con- 
dition; their hats are light things that merely rest 
on the hair, and, finally, the fat layer of the scalp, as 
of the skin generally, is more abundant in women than 
in men and atrophies later in life. Man sometimes is 
inclined to have it that baldness is a sign of intelligence 
and a result of mental labor and that this is the reason 
it is commoner in men. This fiction is one of the few 
consolations that can be urged for the condition, and it 
seems mean to disturb it ; but, truth to tell, there is no 
ground for it. Baldness may make one look wiser, but 



550 CARE OF THE HAIR 

it occurs indifferently in the great and small, and it is 
no more a sign of wisdom than long hair is of genius. 

The broad fact seems to be that in the common 
occurrence of baldness we have a manifestation of 
a transitional stage in man's evolution. The hair on 
the body now is the vestige of a former abundant coat. 
In the economy of nature, structures atrophy and dis- 
appear when they cease to have function, and the need 
of warmth and other protection afforded by the hair 
is no longer of great importance to man. Man now 
uses a hat instead of relying for protection for his head 
on a shock of hair as his ancestors did, and, as a result, 
in spite of all his coaxing, the shock of hair is gradu- 
ally vanishing. This does not mean that you and I can 
save our hair by discarding our hats. We are a result 
of our ancestors, and to save our hair we would have 
to discard the hats of all our ancestors for scores of 
generations back. 

According to this view, heredity is one of the great 
causes of baldness, and all statistics indicate that this 
is true. In the statistics of Jackson and of White, the 
condition is due to heredity in from 30 to 40 per cent, 
of the cases. 

Mistreatment of the hair is also an important factor 
in the production of baldness. Daily wetting of the 
hair, especially if no attention is given to drying it, 
keeping it poor in oil by excessive use of soap and 
water without supplying any fat in place of that 
removed, failure to keep it clean, excessive exposure 
to sunlight, the indiscriminate use of drugs, particu- 
larly "hair tonics," and overzealous treatment by 
barbers and hairdressers — all of these causes are 
influential in the production of baldness, and are to be 
guarded against, particularly in the care of the hair of 
those who have already a predisposition to the con- 
dition. 

The effects of heavy and tight hats by interfering 
with the circulation of the scalp is considered to be of 
great importance, and there can be little doubt that it is 
a factor to be considered. Hats should be light. They 
should provide for circulation of air, and should not 
bind the head. It can at least be said for women's hats 
that usually they are better in these respects than 
men's. 



PREVENTION OF BALDNESS 551 

But after all other factors have been considered, we 
must still come back to seborrheic dermatitis — dan- 
druff — as the most important cause, and the one to 
which most care must be given in preventing baldness. 
According to White's statistics, it is a factor, and per- 
haps the chief factor, in 79 per cent, of the cases ; 
according to Jackson's, in 72 per cent., and according 
to Elliot's in 91 per cent. 

PROPHYLAXIS 

It is apparently little considered by the average indi- 
vidual that the hair should receive as particular care 
as do the teeth and nails. To be sure, it is the custom 
of most people to comb their hair, but this is generally 
done for the cosmetic rather than for hygienic effect. 
By improper care of the hair great harm can be done, 
and conversely, people who desire to preserve their 
hair in good condition should take pains to encourage 
its healthy growth. Many people overdo the matter 
of making applications to the scalp, applying strong 
alcoholic preparations or other socalled tonics too fre- 
quently. Others, with an excess of pains, bathe it too 
frequently, especially with cold water, as is the case 
with people who take a daily cold shower bath. Others 
indulge too frequently in the luxury of a shampoo. 
While occasional washing of the hair is beneficial, too 
frequent application of water to the hair does harm by 
withdrawing the natural oil from the hair and scalp. 
The best authorities advise shampooing the scalp not 
more frequently than once a week and not less fre- 
quently than once a month. Probably nothing better 
can be used on these occasions than Castile soap and 
warm water. f ; ; \' 1 

With women, the case is somewhat different, but 
they have their special unhygienic practices which must 
be mentioned and condemned, especially the curling of 
the hair by winding it about hot curling-irons or doing 
it up in curling papers over night. 

In women, if hair is found to be cracking at the 
ends and becoming thin and unhealthy, the ends should 
be cut off. 



552 TREATMENT OF BALDNESS 

The popular remedies to prevent falling of the hair 
would fill an encyclopedia. Vibratory and electrical 
treatments, hair tonics that feed the hair roots, as 
though they grew out of the scalp like broom-sedge out 
of an old field, neat's-foot oil and crude kerosene, mas- 
sage and mange cures, all have their futile trials. 
Among them must also be included a method highly 
recommended by many barbers and beauty specialists, 
namely, singeing the hair. This is recommended to 
overcome splitting at the ends and to prevent falling 
of the hair, the reason for the latter being that it 
"closes the pores and keeps the fluid in the hair." With 
the long hair of a woman which has a tendency to split 
at the ends, it is possible that singeing the tips may be 
of some use; it substitutes a charred blunt end of 
fused horn for one tapering to the point or cut clean 
across. But even in cases of this sort it is less useful 
than greasing lightly the hair and thus supplying the 
fat which is lacking in such hair. For the hair of 
men, which is kept short, singeing is not of any use 
in preventing the splitting ; hair which is not allowed to 
grow to its natural length does not split, unless it has 
a deep-seated disturbance for which there is no such 
simple remedy. Of course singeing the hair-ends in 
order to prevent the fluid in the hair from escaping, 
like sap from a tree, is based on an entire misconcep- 
tion of the hair's structure and nutrition. The hair 
does not contain any more sap than a buggy whip; it 
is not nourished by any fluid in it, but by the blood 
plasma that reaches only the hair root. The hair above 
the skin surface is a spine of horn, which is even oiled 
from without, and singeing its tips has no effect what- 
ever on either its nourishment or its growth. It is 
certain that singeing the hair is of no value in pre- 
venting its fall; in fact the only value the procedure 
has is to the zealous hairdresser who gets his little fee 
for doing it — unless it is worth a dollar to the seeker 
after hair to think he is doing something, even if he 
is not. 

TREATMENT 

The treatment of baldness, whether due to a local 
inflammation of the scalp, or to the result of some 
general disturbance of nutrition, is a somewhat puz- 



TREATMENT OF BALDNESS 553 

zling matter. The treatment adopted must be con- 
tinued for several weeks, or even months, before a 
result of much importance can be observed. Obviously 
at first the constitutional condition of the patient should 
be carefully inquired into, and any disturbance of it 
should be promptly remedied. If care and worry are 
apparently important factors in the disease, these 
should be remedied as far as possible. If the digestion 
is not properly performed, measures should be adopted 
which will correct it. 

Certain internal remedies have appeared to have 
some control over the nutrition of the skin and scalp. 
Perhaps none surpasses arsenic in this respect, and in 
many cases the use of this drug will seem to contribute 
to a favorable result. If anemia is present, iron may 
be combined with arsenic. For instance : 

Gm. or Cc. 

B Arseni trioxidi |04 gr. V 2 

Massae ferri carbonatis 2\ or 3 ss 

M. et fac pilulas 20. 

Sig. : Take one pill, three times a day, after meals. 

Another drug which has appeared to have a selective 
action on the skin and scalp is sulphur, and in some 
cases this drug has been given with benefit, especially 
if there is constipation, or if there is observed a ten- 
dency to suppurative inflammation of the skin. 

The question of local applications to the scalp is 
one which must be approached with some hesitation. 
The variety of drugs which have been recommended 
for application to the scalp to stimulate the growth of 
the hair is so great that one naturally feels suspicious 
in regard to the value of any one. This, however, 
must not discourage the physician from trying to select 
a suitable one which will prove of benefit to his patient. 
If dandruff is abundant on the scalp, one of the sim- 
plest applications is a solution of borax, with glycerin 
and water. 



Gm. or C.c. 



B Sodii boratis 4 

Glycerini 25 

Aquae q. s. ad 200 



Si 
or A3 v 
fllvi 



M. Sig. : Shake, and apply externally twice a day. 



554 TREATMENT OF BALDNESS 

This, like all applications designed for use on the 
scalp or for the purpose of stimulating the growth of 
the hair, should be applied to the scalp and not to the 
hair. This may be accomplished by using a comb to 
part the hair, separating it so that the application may 
be made directly to the scalp, and when the application 
has been made along one part, making successive appli- 
cations along other parts, until the entire scalp has 
been treated. 

Another remedy which has been extensively used 
for the relief of dandruff is resorcin. This may be 
used in the form of either a lotion or an ointment. 



Gm. or C.c. 



Ifc Resorcinolis 6 

Alcoholis 75 

Aquae q. s. ad 200 



3iss 
or AS iii 
A3 viii 



M. Sig. : Shake and apply to the scalp twice a day. 

Or: 

Gm. or C.c. 

IJ Resorcinolis 150 gr. x 

Adipis lanae hydrosi ... 25] or 5 i 

M. Sig. : Rub into the scalp twice a day. 

These remedies are especially useful when there is 
any evidence of inflammatory action in the scalp 
because of their soothing and anti-inflammatory action. 
In these cases remedies which are stimulating should 
be avoided. If there is no evident pathologic process 
going on in the skin except the falling of the hair, 
more stimulating remedies may be applied. Of these 
the most important are alcohol, quinin, cantharides, 
and ammonia. These, with resorcin, which has teen 
already mentioned, are the fundamental ingredients of 
most popular hair tonics. Bay rum, a favorite appli- 
cation to the hair with. many people, owes its pleasant 
effect largely to the alcohol contained in it. 

The tincture of cantharides is often combined with 
alcohol and castor oil, as in the following prescription : 



Gm. or C.c. 



Ifc Tincturae cantharidis 10 

Olei ricini __ 5 

Alcoholis q. s. ad 100 

M. Sig. : Apply externally. 



A3 iii 
A3 iss 
flSiv 



URTICARIA 555 

When corrosive sublimate is used the proper strength 
is 1 part to 2,000 or. 3,000 of water. 

A sulphur ointment may sometimes be used with 
advantage. 

URTICARIA 

The causes of simple urticaria are food (protein) 
poisoning, intestinal parasites, poisoning by certain 
drugs, disturbances of the liver or kidneys, gout, con- 
ditions associated with an increased amount of uric 
acid in the urine, constipation, an abnormally dry skin, 
and, in fact, anything that impedes normal elimination. 
Circulatory disturbances, especially when combined 
with high blood pressure or arteriosclerosis, may be 
factors in causing urticarial eruptions. 

Urticaria may occur, however, from almost any 
feverish condition or from any infection, and simply 
becomes, then, an added symptom. Most frequently 
urticaria is the most important symptom and, from its 
intense itching, is the cause of the patient seeking 
medical advice. 

The following treatment of simple urticaria is gen- 
erally efficient, namely, catharsis, a limited milk or 
cereal diet, large amounts of water, the administration 
of alkalies, such as potassium citrate in 2 gm. (30 
grain) doses, given four or five times in twenty-four 
hours, or some other alkali, if preferred. Potassium 
citrate may be given as follows : 

Gm. or C.c. 

B Potassii citratis 401 or 3x_ 

Aquae gaultheriae 200| A3 vi 

M. Sig. : Two teaspoonfuls, in water, every four hours. 

If it is known that the stomach and intestines 
have been irritated, bismuth subcarbonate and sodium 
bicarbonate should be administered, and, if the patient 
does not quickly recover, some form of calcium should 
be given. 

The patient should be kept cool. Thin and non- 
irritating underwear should be used. If the patient is 
a child or one in whom the condition tends to recur, 
linen or silk underwear should be worn. Warm baths, 
the water made alkaline with sodium bicarbonate, are 
soothing to urticarial patients, and will relieve the itch- 



556 TREATMENT OF URTICARIA 

ing. The skin should not be rubbed, but should be 
mopped, lest the drying process cause irritation and 
more itching. The localized spots may be sprayed with 
alcohol, cologne, or even mild acid applications, such 
as vinegar. Phenol solutions have long been used to 
dull the irritability of the peripheral nerves; a 2 
per cent, solution, with or without glycerin often 
suffices, as : 

Gm. or C.c. 



B Phenolis liquefacti 4 

Glycerini 25 

Aquae menthae piperitae. . . . 

# q. s. ad 200 

M. Sig. : Use externally as a lotion. 



Si 
or A3 i 

flSvii 



[The preceding should be well shaken and should be 
labeled as poison.] 

Sometimes such applications as "extract of witch- 
hazel" or a bland oil like almond oil will be soothing 
to the irritated skin. If the urticarial spots are not in 
large numbers, such applications as camphor or chloral, 
with or without menthol, are often valuable, as: 

Gm. or C.c. 

B Camphorae 

Chlorali hydrati aa 2 or 3 ss 

Glycerini 25 A3 i 

Alcoholis q. s. ad 100 A3 iv 

M. Sig.: Use externally. [Shake, and label as poison.] 

Gm. or C.c. 

3ss 



gr. xv 

flSi 

flSiv 



fy Camphorae 

Chlorali hydrati aa 2 

Mentholis 1 

Glycerini 25 

Alcoholis , q. s. ad 100 

M. Sig. : Use externally. [Shake, and label as poison.] 

Various dusting powders are often of benefit, espe- 
cially in children suffering from this condition. The 
simplest is powdered starch or a talcum powder. Some- 
times stearate of zinc, with or without menthol, is of 
value as tending to adhere to the region that is 
irritated. A simple formula frequently recommended 
is Anderson's dusting powder : 

Gm. or C.c. 
B Amyli pulveris 24 

Zinci oxidi 6 

Camphorae pulveris 2 

Mice et fiat pulvis. 






3 vi 





3 iss 





3 ss 



TREATMENT OF URTICARIA 557 

When urticaria continues or recurs, as it does occa- 
sionally in its milder forms, the whole physical condi- 
tion, diet, and personal hygiene, of the patient must be 
very carefully investigated. Some wrong condition 
will be found, and when it is corrected the disturbance 
will disappear. Especially must the intestinal digestion 
be studied. If constipation or indigestion is present 
measures to prevent the absorption of the irritants will 
generally cure the urticaria. Occasionally in young or 
older persons in whom a high tension or arteriosclero- 
sis has begun or who have insufficient kidneys, condi- 
tions of the skin exist that cause temporary reddening, 
and perhaps itching, with the least irritation. The 
patient may be tested as to his sensitivity to various 
food substances by beginning with a simple milk diet 
and gradually adding one article after another until 
he finds the one that invariably produces recurrence 
of attacks. Skin tests with extracts of various pro- 
teins may discover a food that is at fault. 

The skin may be so hypersensitive as to allow of 
what is termed "dermographia." This condition is a 
pseudo-urticaria, and the treatments that tend to relieve 
urticaria will generally relieve this condition. 

When there are angioneurotic edemas, a diminution 
of the sodium chlorid in the food will often be a valu- 
able adjunct to the other treatment inaugurated. This 
is especially true if the kidneys are at all insufficient. 

Giant urticaria, on the other hand, is a serious, dan- 
gerous affection, especially if it attacks the face and 
mouth, as, when present elsewhere, it is likely to do at 
any moment, and dangerous swelling in the throat and 
larynx may occur. This condition should be treated 
energetically, and the patient should be under close 
observation. 

The treatment of giant urticaria is catharsis with 
calomel and saline cathartics ; a milk diet, if milk agrees 
with the patient ; or a plain water diet ; or a cereal diet. 
Calcium should be given, and alkalies in large doses. 
Occasionally, large doses of quinin, such as 60 eg. ( 10 
grains) twice a day, or good-sized doses of antipyrin, 
as 1 gm. (15 grains) three times a day, have seemed 
almost specific. Atropin pushed to physiologic action 



558 ROENTGEN DERMATITIS 

is sometimes of value. The exact cause of this serious 
condition has not been determined. Doubtless, how- 
ever, it is anaphylactic and due to protein poisoning. 

ROENTGEN DERMATITIS 

The wide use of the roentgen ray in the treatment 
of various diseases has led to the occurrence of roent- 
gen burns with dermatitis and severe rapidly growing 
new growths. Caldwell, Abbe and others are con- 
vinced that the most practical, easiest applied treat- 
ment is the use of radium. The application of radium 
is free from pain and under its influence the lesions 
seem to retrogress. The effectiveness of the freezing 
methods and of the electric-spark methods cannot be 
questioned, but they are both painful. Sparks can 
sometimes be applied in situations impossible to reach 
with liquid air or carbon-dioxid snow. Of the two 
methods, freezing is somewhat less painful. The 
value of surgery in such cases has been demonstrated 
beyond any shadow of doubt, but these operations 
are dangerous and they call for exceptional surgical 
judgment and technical skill. Under the best condi- 
tions excision cannot be safely done ordinarily with- 
out sacrificing healthy tissue. The possibility of has- 
tening metastasis must always be considered. 

Dodd has found the following application simple 
and efficacious in the treatment of the ordinary acute 
reaction following roentgen-ray exposure: 

Gm. or C.c. 

IJ Zinci oxidi 25 Si 

Phenolis 2 or 3 ss 

Glycerini 4 . 3 i 

Aquae calcis 200 Sviii 

Shake well and bathe area for five to ten minutes, 
twice or three times a day. Avoid all heavy dressings 
and, when possible, expose the lesion to air. Do 
not apply this remedy on a dressing, but sop it on and 
let the air get to the lesion. 

A valuable lotion in these cases is Liquor Alumini 
Subacetatis (Burow's solution) 1 part to 15 parts of 
water. It may be used in the form of a wet dressing. 
Between attacks the hands may be kept soft by appli- 
cation of some bland ointment such as cold cream. 



TREATMENT OF CHAPPED HANDS 559 

CHAPPED HANDS 

The chief reason for chapping of the hands is the 
lack of fat in the skin in cold weather. Fat produc- 
tion in the skin is at a minimum in cold weather, 
because of the diminished sebaceous and sweat secre- 
tion. This and the dry air of winter make the skin 
dry and vulnerable at the very time when the cold air 
itself is irritating. This combination leads readily to 
chapping if the hands must be exposed much to soap 
and water, and particularly if the irritation of antisep- 
tics is added, as in the case of physicians and nurses. 

The first thing to do to prevent or overcome the con- 
dition is to supply, by greasing the skin occasionally, 
the lacking fat in the skin. Almost any bland fat or 
semisolid hydrocarbon will do for this purpose, but 
nothing is better than a well-made cold cream. The 
next and more difficult thing to do is to avoid soap and 
water — especially soap — as much as possible; and it 
is here that hand lotions serve a very useful purpose. 

Hand lotions are generally of two types: (1) 
glycerin solutions of the glycerin, rose water and ben- 
zoin kind, and (2) gelatinous liquids made with traga- 
canth, quince seed, or some other water-soluble colloid. 
The glycerin lotions work well with some skins and 
are the most satisfactory to an occasionaj individual ; 
but as a rule they are not the best, first, because the 
glycerin tends to make drier a skin already too dry 
and, second, because these lotions have little or no 
detergent effect and do not clean the skin. 

The tragacanth and quince-seed lotions are better, 
and of these the tragacanth lotions are certainly as 
good as any other and are very cheap and easy to make. 
A formula for such a lotion given by Pusey is as 
follows : 

Gm. or C.c. 

I£ Tragacanth 4 3 i 

Glycerin 60 3 ii 

Boric acid 12 or 3 in 

Water q. s. ad 500 O i 

Oil of bergamot 60 gr. x 

The oil mentioned being added as a perfume might 
be omitted, according to the wish of the prescriber. 



560 CHILBLAIN 

The boric acid, glycerin and water are first mixed, 
the tragacanth added and the mixture agitated until 
the tragacanth is dissolved. This makes a rather thick 
mucilage ; it can be changed to any consistency desired 
by slight increase or decrease in the amount of 
tragacanth. 

A lotion like this has a considerable detergent effect ; 
it is a fair substitute for soap, and if it is freely 
rubbed over the hands and wiped off, either with or 
without the use of water, cleans the skin of all but the 
most tenacious dirt. It, of course, cannot be effectu- 
ally used as a complete substitute for soap. Such a 
lotion has the advantage over soap that it not only is 
not irritating to sensitive skin but also is bland and 
soothing. It thus tends to prevent and eventually to 
cure chapping of the hands. 

CHILBLAIN 

The conditions favoring chilblain are impaired and 
weak circulation. Hence it is seen chiefly in the lower 
extremities, especially in the feet, but may affect also 
the fingers, ears, nose and cheeks, parts especially 
exposed to the cold. 

The principal manifestations of the disorder are a 
burning heat, with itching and redness. These symp- 
toms are usually worse at night. 

Rapid change of temperature or prolonged exposure 
to cold, and especially to cold combined with dampness 
and moisture, undoubtedly produces slight histologic 
changes, of an inflammatory character, in the cutaneous 
structures. These have been designated by some writ- 
ers as chronic erythematous dermatitis. 

Relief is sometimes obtained by painting the affected 
part with equal parts of tincture of iodin and tincture 
of opium. Oil of pepperment diluted with from one 
to six parts of glycerin has been recommended as 
affording relief. 

Prophylactic measures may be taken against chil- 
blains before the advent of cold weather, or between 
exacerbations. The patient should be instructed to 
wear warm, loose woolen stockings and warm shoes. 



CHILBLAIN 561 

The feet should be bathed in warm water daily, and 
after the bath should be rubbed briskly, quickly dried, 
and a bland powder dusted on. 

When the chilblains have developed, more active 
treatment should be employed. If the patient's general 
health is below normal, tonics are indicated. When the 
condition is very acute, it is well to use soothing lotions, 
as a calamine lotion, freely for a time. In the less acute 
cases, the greatest improvement is usually obtained with 
the use of stimulating applications, but the large number 
of these which have been recommended shows that no 
one of them is successful in all instances. Ichthyol, 
either in the form of a 25 per cent, ointment, or used 
in lotion form, one part to two or three parts of water, 
is perhaps most commonly recommended. Rubbing 
with oil of turpentine, pure or diluted, with camphor- 
ated soap liniment or with phenolated oil, is sometimes 
employed. In the stubborn cases, the use of the gal- 
vanic current has at times produced a favorable effect, 
the positive pole being applied to the affected part, the 
negative pole to a neighboring region, near the truncal 
nerve. 

If the chilblain undergoes ulceration, treat as any 
other ulcer. 

When the inflammation proves resistant to treatment, 
the possibility that the affection is something more 
serious than chilblains, perhaps either lupus erythema- 
tosus or Renaud's disease, must be considered. 

Hot air treatment has been found useful when the 
condition is of long standing. 

The following simple combinations may be of benefit 
for chilblains, painful corns or bunions: 

Gm. or C.c. 

Ifc Mentholis 1 gr. xv 

Methylis salicylatis 8 or 3 ii 

Adipis lanae hydrosi- . 25 3 vi 

M. Sig. : Apply a small quantity frequently, rubbing in 
until absorbed. 

Gm. or C.c. 

I£ Camphorae [... 1 50 gr. xx 

Balsami peruviani 50 gr. vii 

Olei amygdalae dulcis 10 or 3 iii 

Adipis lanae hydrosi 

Aquae rosae aa 25 Si 

M. Sig. : Use externally. 



562 TREATMENT OF FROSTBITE 

FROSTBITE 

If chilblain is regarded as a chronic affection gen- 
erally due to the action of cold, frostbite may be 
regarded as an acute affection due to the action of cold. 
When a portion of the body not properly protected is 
exposed to intense or extreme cold the tissues become 
affected, and if the cold is sufficiently intense and the 
exposure is sufficiently prolonged the part becomes 
frozen. Individuals in whom the circulation is weak, 
particularly the young, the old and the debilitated, 
are especially likely to suffer from intense cold. Like- 
wise those parts in which the circulation is least active, 
and which are least protected by clothing, as the ears, 
hands and feet, are prone to suffer. 

Different degrees of frostbite are recognized. In the 
slighter forms, the smaller arteries become contracted, 
the circulation becomes slow, and there is venous 
stasis. This is accompanied by a change in the various 
structures, and also in the blood contained in the 
vessels of the affected part. 

If the cold is more intense or the exposure is more 
prolonged, vesicles and blisters or blebs, containing 
often sanguinolent fluid, form. 

Finally, if the exposure is sufficiently severe and 
sufficiently prolonged, the entire part becomes con- 
gealed, and freezing and gangrene result. 

Locally the part becomes cold, pale, or bluish, 
shrunken or wrinkled, and there is loss of sensation 
and diminution, or entire loss, of the power of motion. 

Constitutional symptoms vary with the condition of 
the individual and the extent of the lesion. Loss of 
energy, fatigue and weakness are early symptoms. 
These may be followed by indisposition to continued 
exertion, difficulty of speech, delirium, coma, and 
death. 

The rule for treatment must be to save as much of the 
injured extremities as possible, and as it is impossible 
to say how much of the damaged tissues will survive, 
immediate or early amputation is absolutely contraindi- 
cated. The best treatment at first is friction with snow 
or cold water in a cold room, the changes to a 
warmer atmosphere being gradually brought about. 
After the friction the limbs should be raised on 



ECZEMA 563 

pillows and swathed in cotton-wool, which can be 
held in position by bandages applied loosely so as to 
avoid any danger of constriction. If blisters form, or 
discoloration of the toes or other parts shows that 
gangrene is probable, the whole foot should be cleansed 
aseptically and then strips of sterilized gauze should 
be applied between the toes and the same gauze made 
to cover the whole foot, which is then enveloped in 
sterilized cotton-wool. Any blisters — which will be 
found to contain dark blood-stained fluid — should be 
snipped and carefully dried and dressed. 

Every effort should be made to keep the parts dry 
and sterile. If gangrene occurs the surgeon should 
on no account make too great haste to amputate, as 
the tissues adjoining the line of demarcation become 
more and more healthy and the line of granulation tis- 
sue between the dead and living tissues, if kept asep- 
tic, gives rise to little discharge and can be kept aseptic 
by daily dressings. Ultimately, when and how to oper- 
ate become surgical decisions. 

ECZEMA 

Eczema is a non-microbic inflammation of the skin, 
occurring probably from a number of different causes, 
external and internal, of a toxic, digestive or nervous 
nature. It is characterized by inflammation and red- 
ness, vesication, weeping and exudation, formation of 
crusts and scales, ill defined lesions, spreading periph- 
erally and, as a rule, intense itching. 

Heimann, Knowles and others have contended that 
the condition is synonymous with dermatitis. Knowles 
(Journal A. M. A., Jan. 13, 1917, p. 79) found that of 
thousands of cases, almost one third were of definite 
external origin. About one sixth of all cases of this 
affection are caused by the occupation of the individual. 
Micro-organisms play only a secondary role in the 
causation of the disease. Practically every occupation 
and every irritant may produce an eczema. The por- 
tions of the skin exposed to the irritant determine the 
site of the outbreak. The eruption not infrequently 
extends beyond the irritated areas, at times being 
observed on distant parts of the cutaneous surface, and 
also generally over the body in certain instances. The 



564 TREATMENT OF ECZEMA 

usual type of eruption noted is the vesicular or the 
erythematosquamous. The eruptions last for weeks, 
months and years, and show a marked tendency to 
relapse. It is rather hard, he says, to explain the sus- 
ceptibility of some persons to certain irritants, while 
others are not affected, except on the theory of a pure 
idiosyncrasy, an anaphylactic tendency causing sensi- 
tization of the skin. 

Charles J. White (Journal A. M. A., Jan. 13, 1917, 
p. 81) made skin tests with extracts of food substances 
on a large number of persons with eczema and found 
specific sensitization. He also made examinations of 
the stools as to the presence of excess of fats, soaps 
or starches. He concludes that a goodly proportion 
of persons afflicted with eczema show sensitization to 
various types of food and that a much larger propor- 
tion are unable wholly to digest all the elements of 
the food they eat. 

TREATMENT 

A thorough investigation of the patient's history 
with particular reference to occupation should be 
made to find if he is being exposed to any particular 
irritant. Persons who are susceptible to chapping 
should be careful to dry the hands thoroughly after 
washing and perhaps apply regularly a protective lotion 
such as is described for that condition. Soap should 
be used very sparingly, if at all. 

The diet should be very simple, avoiding particularly 
alcohol, coffee, all spiced and highly seasoned foods 
and large quantities of meat. The bowels should 
move well daily. In some cases it may be necessary 
to make an analysis for particular sensitization to 
some food, substance as described under urticaria. 
Water should be drunk abundantly. 

Internally no drug has any special value. Many 
have been tried and have seemed at times to yield 
good results, only to fail in the next case or later in 
the same case. 

As indicated by Eisenstaedt (Jour. A. M. A. 74: 
667, 1920), the dietary management of a patient is one 
of the most important features in the treatment of 
eczema. Some patients do not tolerate carbohydrates 



TREATMENT OF ECZEMA 565 

well, and in these cases a reduction of carbohydrate 
intake almost to complete elimination is necessary. It 
is well to examine the urine, noting any change from 
normal; sugar especially should be looked for. Some 
cases of carbohydrate intolerance, while showing no 
sugar in the urine, present quite constantly an increased 
amount of sugar in the blood. 

Other patients are intolerant of sodium chlorid, and 
some eat excessive quantities of nitrogenous articles 
of food. 

In persons past middle life suffering from eczema, 
nephritic changes should be looked for, and if present, 
properly treated. Other patients with eczema present 
an anaphylactoid if not a true anaphylactic reaction 
against specific proteins or proteins of certain groups, 
among which may be mentioned egg albumin, pork, and 
the protein of cow's milk. The patient himself may 
connect the ingestion of certain articles of diet with 
the appearance of the eruption. It is well, therefore, 
to put the patient on an absolutely bland diet, which is 
readily digestible and whcih contains little or none of 
the substances that experience has shown may be pro- 
ductive of eczema. 

In some patients the predisposition to eczema can in 
a greater or less degree be controlled by organotherapy. 
However, as Eisenstaedt points out, the physiology and 
therapeutic uses of the ductless gland substances are 
in general so poorly understood that it is impossible 
to give clear-cut indications for their use, and the sug- 
gestion is offered merely as one that they may some- 
times be helpful in the management of eczema. 

Local treatment is largely symptomatic. It includes 
removal of crusts, antiseptic treatment if there is 
secondary pus infection, protection from itching and 
irritation, and various local preparations for curative 
purposes. To remove the crusts Sequeira recommends 
a simple boric starch poultice. One teaspoonful of boric 
acid and one half an ounce of starch are mixed into a 
paste with a small quantity of cold water. On this are 
poured 15 ounces of boiling water and well stirred. 
This is spread on gauze and applied to the lesions 
which, after softening, are removed. Until the sup- 
puration is relieved the wet dressings of boric acid or 



566 TREATMENT OF ECZEMA 

of 1 per cent. Burow's solution (liquor alumini sub- 
acetatis) may be continued. 

If wet dressings are difficult to handle, antiseptic 
ointment such as boric acid, 4 gms. to an ounce, or 
ammoniated mercury, 1 gram to the ounce, may be 
utilized. 

When the suppuration is relieved it is necessary to 
treat the exudative condition. Soothing antipruritic 
lotions and subsequently fatty preparations are most 
useful. Among the lotions used are the Burow's solu- 
tion, 1 gram to an ounce of water; phenol, 1 gram to 
an ounce of water; or camphor-chloral, 1 c.c. to an 
ounce of water. Relief is also obtained by the appli- 
cation of cloths wrung out of hot water or water con- 
taining one-half teaspoonful of baking soda to a pint 
of water. Following the lotions a simple zinc oint- 
ment may be applied. As the weeping subsides a lotion 
containing a residual powder may be used such as a 
calamin lotion with 1 per cent, phenol or liquor alumini 
subacetatis (1 per cent.). With the lotion may be used 
mild ointments, such as fresh zinc or rose ointment 
and antipruritic combinations with phenol, camphor 
or menthol. Or, as a substitute, Lassar's paste with 1 
per cent, of salicylic acid may be tried. If it dries 
and cakes it may be removed with oil. 

In acute papular or papulovesicular eczema the skin 
may be so irritable that ointments are not well toler- 
ated. Here Eisenstaedt {Jour. A. M. A. 74: 667, 1920) 
recommends applications of a mild alcoholic solution 
of 0.5 per cent, of salicylic acid followed by the use of 
a bland dusting powder every three or four hours. 

Gm. or C.c. 

ty Salicylic acid 112 

Diluted alcohol 240|. 

Label: Apply to affected parts. 

Gm. 

B Starch I 

Talcum aa 60| 

Label : Use as dusting powder. 

After the acute condition subsides dusting powders 
containing equal parts of zinc oxid and starch or 
talc with salicylic acid ; phenol, tar, or salol, 1 per cent, 
or boric acid, 15 per cent, may be utilized. Or at this 



TREATMENT OF ECZEMA 567 

time the soothing tragacanth jelly described for treat- 
ment of chapping may be applied. 

Or the following may be tried : 

Gm. 
I£ Zinc oxid 

Talcum aa 15| 

Petrolatum 30| 

Label : Apply to inflamed parts. 

Gm. or C.c. 
1^ Zinc oxid 

Starch 

Glycerin 

Distilled water aa 15 

Label : Zinc oxid lotion. 

The skin may return to normal under this treatment. 
Usually, however, stimulating applications are neces- 
sary to complete the treatment and to rid the skin of 
the results of the inflammatory process. These must 
be applied with great caution, to prevent setting up 
the troubles anew. Small doses of tar, 7% grains to 
the ounce, may be utilized in ointments. The quantity 
may be gradually increased to double or four times 
this strength. Tar preparations, such as the oil of cade 
or rectified oil of birch tar, ichthyol and its allied 
preparations, or salicylic acid, may be added. 

Gm. or C.c. 

B Zinc oxid 

Talcum aa 10 

Petrolatum 20| 

Rectified oil of birch tar... \3 
Label : Tar-zinc paste. 

Other drugs used are mercury, phenol, sulphur, 
betanaphthol or salicylic acid in ointments beginning 
with weak concentrations and gradually increasing to 
perhaps 15 grains to an ounce of ointment. 

Old chronically exacerbating eczemas are most dif- 
ficult to treat satisfactorily without all the facilities 
available to those specializing in the treatment of skin 
diseases. It is not wise, therefore, to hesitate too long 
before giving patients the advantage of such expert 
assistance. 



568 HYPERKERATOTIC ECZEMA 

HYPERKERATOTIC ECZEMA OF PALMS AND SOLES 

This type of eczema follows exposure of the 
hands to injurious influences such as rough weather, 
water, cleansing agents, chemical solutions and various 
traumatisms, and the encasing of the feet in ill-fitting 
and deforming shoes, which produce callosities and 
breaking down of the arch, thereby increasing sweat- 
ing of the soles and resulting in maceration of the 
keratotic, thick epithelium. 

Locally a plaster may be employed, containing 5 
per cent, salicylic acid. 

This is applied on the fingers and covered with zinc 
oxid adhesive plaster, so as to intensify its action. 
This is changed once in twenty-four hours. Under its 
use the hard callus of the fingers melt down, and the 
skin becomes smooth and supple. This plaster cannot 
be applied to the feet as it would crumple up in walk- 
ing, but an ointment may be prepared of about 12 per 
cent, salicylic acid in equal parts of lanolin and petro- 
latum, as follows : 

Gm. or C.c. 

ty Acidi salicylici 8| or 3 ii 

Adipis lanae hydrosi I 

Petrolati aa 30| Si 

M. 

This is applied in the morning, so that in walking it 
will be massaged into the skin. A few days later, when 
the patient is able to resume work, an ointment com- 
posed of one part of mercury in ninety-nine parts of 
simple ointment is used. 

Gm. or C.c. 

I£ Hydrarg. salicylatis 11 or gr. xv 

Unguenti 99) 5 iv 

The official unguentum acidi borici often acts well; 
the white precipitate in 2 to 4 per cent, strength in an 
ointment, may, in some instances, be better than the 
salicylate of mercury as given in one of the above pre- 
scriptions. According to Eisenstaedt, the first thera- 
peutic indication is the removal of horny accumulation, 
so that the underlying inflammatory process may be 
influenced by the medication ordered. This can be 
accomplished by energetic therapy which produces 



SWEATING OF THE FEET 569 

maceration, for which a suitable ointment applied to 
a mull bandage and brought into intimate apposition 
with the skin is very useful. 

Gm. or C.c. 

f$ Diachylon ointment 301 

Oil of cade \6 

Label: Apply on linen and bandage. 

During and after this mode of treatment it is well 
to use a formaldehyd ointment, because of the marked 
hyperhidrosis which is frequently associated with this 
form of eczema. 

Gm. or C.c. 

fy Solucion of formaldehyd 51 

Menthol |5 

Wool fat ' | 

Petrolatum aa 25| 

Label : Formaldehyd ointment. 

Some of the best results in treating eczema of the 
soles, and especially of the palms, have been obtained 
by Montgomery and Culver by the use of roentgen 
rays, after all other lines of treatment have failed, for 
months or even years. 

SWEATING OF THE FEET AND AXILLAE 

Excessive perspiration of the feet and the skin of 
the axillae is a most annoying condition, and one that 
frequently is difficult to control satisfactorily. 
Besides keeping the parts properly bathed and cool, 
attention should be given to the clothing and shoes. 
Rubber soled shoes are objectionable if there is 
excessive sweating of the feet. Air-tight dress shields 
should likewise be discarded. 

Various remedies have been suggested. Most 
recent and quite efficient is the remedy suggested by 
Stillmans. He states that a 25 per cent, solution of 
aluminum chlorid in distilled water, dabbed gently 
on the part every second or third day and allowed 
to dry, will cause a rapid amelioration of the excessive 
sweating. Three applications are usually sufficient. 
If the condition recurs, the treatment may be 
repeated. 

An older remedy is the application of a 2 per cent, 
solution of the official liquor formaldehydi in water 



570 BURNS 






to the axillae, and up to a 5 per cent, solution for 
the feet. 

Pure glycerin rubbed on the feet will at times stop 
offensive sweating. Potassium permanganate solu- 
tions of about 5 parts to 1,000 have been found effi- 
cient as a wash for the feet. 

Tannic acid may be used as follows : 

Gm. or C.c. 
B Tannic acid 5 

Alcohol 100 

Water up to 200 

Use as a wash twice a day. 

Various drying powders have also been suggested 
for this condition, as : 

Gm. or C.c. 

$ Boric acid. 101 

Purified talc 100| 

Gm. or C.c. 

H Salicylic acid 5 

Bismuth subnitrate 40 

Zinc stearate 20 

Gm. or C.c. 

R Salicylic acid 2 

Bismuth subnitrate 20 

Starch 20 

In very severe cases, treatment with the roentgen 
ray will control the condition. This treatment, in 
unskilled hands, is not altogether safe. 

The use of the solutions of aluminum chlorid or 
formaldehyd may, in some cases, cause a mild derma- 
titis, perhaps with itching. This may be ameliorated 
with protection of the parts against scratching, and the 
application of ointments, such as cold cream containing 
12 per cent, boric acid, or a calamine lotion. If there 
is much itching, 0.5 per cent, phenol may be incor- 
porated in the calamine lotion. 

BURNS 

It is customary, following Hebra, to classify burns 
by three degrees. This classification is based on the 
extent of the pathology, varying from simple inflam- 
matory reactions of the skin to a primary necrosis. 
In a review of the management of burns Ravogli stated 



BURNS 571 

that the best treatment is that which favors sloughing 
of the burned skin, maintains sterility of the resulting 
wound and promotes granulation and the forming of 
new epidermis. 

In burns of the first degree Ravogli believes that 
the application of a dry powder, such as talcum, bis- 
muth or burnt alum, is the best treatment. Salves 
and baths are inadvisable because of the possibility of 
excoriation and maceration of the epidermis, with sec- 
ondary infection. When there is severe pain a com- 
press moistened with a 2 to 5 per cent, solution of 
aluminum subacetate is applied to relieve the pain. The 
solution used is the liquor alumini subacetatis (Burow's 
solution), one part to fifteen parts of water. As soon 
as the pain is relieved, the skin should be dried and a 
powder applied. 

In second degree burns, as soon as the blisters are 
distended with serum they are evacuated, leaving the 
epidermis in place to protect the papillary layer. Com- 
presses of aluminum subacetate are advised here also. 
The application of compresses moistened with 1 per 
cent, picric acid solution have been advised, and also 
a solution of potassium permanganate of 1 :3,000 or 
1 :4,000. These solutions are difficult to handle and 
stain everything with which they come in contact. 
Over the compresses moist with aluminum subacetate a 
piece of oiled silk, cut to hold the dressing in place, is 
bound. This may be removed at intervals and the 
dressings again moistened. Such oily substances as 
carron oil, or oleum lini and aqua calcis may carry 
infection and should therefore be avoided. When the 
shreds of epidermis forming the blisters are easily 
detached they are removed with a forceps and scissors 
and the whole surface gradually cleared. The exposed 
surfaces may then be exposed to the air, for an hour 
at first, later for two or three hours. The surface is 
then covered with powder and sterile gauze. Little 
points which ooze and granulate are touched with 
3 per cent, silver nitrate solution and are covered with 
2 per cent, boric acid in petrolatum to prevent crust- 
ing. Under such treatment these burns heal in from 
ten days to two weeks. 



572 PARAFFIN TREATMENT OF BURNS 

In burns of large areas of the surface of the body, 
other methods of treatment are often necessary. 

Kuss and others have advocated the covering of the 
burned area with a piece of caoutchouc paper in which 
holes are cut. Through these the serum drains and the 
wound is moistened at intervals with salt solution. 

Parker (Jour, A. M. A., July 3, 1915, p. 16), after 
sloughing of the tissue has taken place, covers the 
wounds or ulcers, especially in burns of the extremi- 
ties, with strips of adhesive plaster. 

After separation of the slough, ribbons of adhesive 
plaster from 1 to l 1 /^ inches wide and long enough to 
cover the area and lap over slightly are placed, leaving 
no granulations exposed. Its function is to keep in 
the serum and prevent cells dying from dryness. Over 
this are placed several layers of gauze to take up the 
secretion that works out between the strips at various 
places. 

The gauze is changed every day, as it becomes soiled, 
and every few days the adhesive plaster. This is 
done by cutting through it with a blunt scissors when 
it immediately falls away from the moist surface to 
which it does not become attached. Pus comes away 
with it. The surface is sponged and a new dressing 
applied. Parker finds that burned areas so treated 
granulate smoothly, with little absorption of toxic 
products and but little pain to patients in changing 
dressings. Skin grafts placed under such dressings 
seem to grow as well or better than under gauze 
dressings. Silver foil dressings are often very suc- 
cessful. 

PARAFFIN TREATMENT 

This treatment has received considerable trial due 
to its extensive use in the war zone. It is chiefly appli- 
cable to first and second degree burns. The lesions 
are carefully washed with some antiseptic solution 
such as hypochlorite or Chloramin-T solutions. They 
are then dried by blotting with gauze or with a jet of 
hot air. Then paraffin — one of the paraffins for film 
preparations mentioned in New and Nonofficial Reme- 
dies — is melted and cooled to about 48 C. to 50 C. It 



PEDICULOSIS 573 

is then sprayed on the wound by a special atomizer or 
painted on with a fine brush. If there is much pain, 
the wound may first be covered with sterile liquid 
petrolatum. The first layer of paraffin is covered with 
a very thin layer of cotton and the whole held in place 
by a bandage. Subsequently the dressings are removed, 
the lesions cleaned in the same manner and again 
dressed. Sloughs and dead tissue are removed as 
found at the daily dressings. 

GENERAL TREATMENT 

As has been mentioned, over large, severely burned 
areas, Reverdin skin grafts may aid epidermization. 

An extensive burn practically always is accompanied 
by some systemic reaction. Patients may be stimulated 
with caffein or strychnin, or morphin may be given 
to relieve the pain. 

Gastroduodenal ulceration, with nausea, vomiting, 
and acute nephritis are not unusual sequellae. In 
such cases alkalinization of the patient and digitalis 
will aid in clearing up the condition. 

As the patient improves, a good diet, plenty of open 
air and the administration of iron aid in improving the 
general condition. 

PEDICULOSIS 

This troublesome condition has long been treated 
by applications of kerosene oil. The kerosene is 
applied, the hair covered with a suitable cap for 
twenty-four hours, then thoroughly washed and the 
nits removed with a fine comb. 

A more recent method of eradicating lice, first 
recommended by Sabouraud, is the use of xylene. 
Xylene (xylol of dimethylbenzine) is a colorless liquid 
coal-tar product. It has a penetrating but not unpleas- 
ant odor, and mixes with alcohol and ether, but not 
with water. It is a strong parasiticide, will rapidly 
destroy lice, and will penetrate their ova and destroy 
them. When undiluted, it causes a sharp, burning sen- 
sation when applied to the skin; but the pain which 
it thus causes does not last long, and it does not seem 
to blister or cause dermatitis. It evaporates when 
exposed to the air or when applied on the surface of 



574 PEDICULOSIS 

the body, and is highly inflammable; consequently it 
should not be used near a fire, or in the evening if 
the artificial light is other than electric. 

Although, as stated, xylene may be used in certain 
places in certain instances in full strength, it is better 
to apply it in combination, and a mixture of equal 
parts of xylene, alcohol and ether is recommended by 
Faniel as safe and efficient. (Presse Med., July 22, 
1915, p. 268.) 

For the removal of lice from the head, cotton is 
soaked in this mixture and the scalp is thoroughly gone 
over with this cotton sponge, and all the strands of the 
hair are drawn through the sponge. Generally with 
one application, and certainly with two applications of 
this treatment, all the parasites and nits are destroyed. 
The disease 'may be cured in half an hour, even when 
the hair is long, as in women and girls. 

If scratching has caused eczema and scabs on the 
scalp, these may be softened by the application of 
petrolatum, and the scabs may be removed later. On 
these excoriated places the mixture of xylene men- 
tioned above is too strong treatment, and Lane (New 
York Med. Jour., Oct. 16, 1915, p. 804) recommends 
in these cases the following*: 

Gm. or c.c. 

B Xylene 4 

Petrolatum 30 

M. Sig. : Use externally as directed. 

The day after this ointment is applied to the scalp 
it may be washed off, and the strands of the hair 
treated with the mixture of xylene, alcohol and ether ; 
and then it may be well to apply this ointment once 
more. As a final treatment of the pediculosis capitis 
a fine-tooth comb may be run through the hair and the 
nits thus removed for cosmetic purposes, although the 
ova have been killed. 

In pediculosis of the pubis or axillae the same mix- 
ture of xylene, alcohol and ether should be used, and by 
the same method. It is well, however, to precede the 
treatment by a warm, cleansing bath, and to follow the 
treatment by another bath. On the scrotum and vulva 
and in the deep axillae the xylene mixture is rather 



PLANT POISONING 575 

painful for a short time, and should be applied gently 
and with care, but the burning will last but a few 
hours. If there are excoriated places on the skin in 
these regions, the ointment recommended by Lane 
should be used in place of the xylene solution. 

PLANT POISONING 
Primrose 

This poisoning is not infrequent, though generally 
perhaps it is unrecognized, the condition being called 
acute eczema. 

Sharpe thinks that the dermatitis not infrequently 
seen on the hands of milkers may sometimes be due to 
the fact that the poisonous substance of the wild prim- 
rose is carried on the udders of the cows. 

It has been noted that primrose plants do not 
readily become infected with insects. Montgomery 
thinks that the cause of this immunity may be the 
poison exuded by the plants. 

The hands and arms are the parts most attacked by 
the primrose, and the symptoms are burning, purring, 
and at times small pin-point blisters. There is also 
a good deal of itching. 

The primary treatment is to recognize and remove 
the cause. Magnesium sulphate solutions are gener- 
ally satisfactory in relieving the inflammation. As is 
true of all acute skin eruptions, catharsis and_a milk 
and cereal diet will hasten the recovery. 

Ivy, Oak and Sumach 

Adelung (Arch. Int. Med., February, 1913, p. 148) 
found that their poisonous juices are chemically iden- 
tical, and this poison is nonvolatile. It has been shown 
that as little as %ooo of a milligram may produce a 
dermatitis. 

It is now known that the poison of the ivy is of a 
resinous nature. As it is generally agreed by analysts 
that the poison is nonvolatile, the assertion that cer- 
tain susceptible persons may be poisoned by simply 
passing by the plants remains to be explained. It is 
certain that neither the pollen nor the plant hairs are 
toxic, so that direct transmission is the only plausible 
explanation. Adelung also found that the poison was 
purely a local one. It is not distributed by the blood. 



576 TREATMENT OF IVY POISONING 

The latent period or length of time from the infec- 
tion to the development of the dermatitis is shorter on 
the parts of the body where the skin is the thinnest, 
such as the face and the inner sides of the arms and 
wrists. As -is well known, there is a varying suscep- 
tibility of individuals, though there seems to be no 
natural immunity (as shown experimentally). It is 
a popular idea, however, and seems to be a fact, that 
some persons may handle the poison ivy, for instance, 
with impunity. On the other hand, susceptible persons 
seem to vary as to their susceptibility in different sea- 
sons or in different years. This may be entirely due 
to the variability of the irritant poison. 

Adelung found that the rhus plant would yield a 
pure toxin of about %ooo of its weight. He believes 
this toxin has a selective action for the epithelial cells. 
Experimentally Adelung could not demonstrate that 
immune bodies were formed in the blood or that there 
were any immune bodies contained in the. blood of an 
individual who was more or less immune to the poison. 
Toyama {Jour. Cut. Dis. } 1918, 36, p. 157) found 
the poisonous ingredient to be a substance which he 
calls "urushiol," which may be isolated from the plants. 

TREATMENT 

If, immediately after exposure to the poison, the 
parts supposed to be affected are washed with soap 
and hot water, dermatitis generally will not occur. If 
it is known that just one small part of the body, as one 
part of the hand or ringer, has touched the poison, the 
full strength tincture of iodin applied to the part will 
destroy the poison, according to Adelung. 

Protection against poisoning is more or less fur- 
nished by oils or fats, as cottonseed oil, smeared over 
the exposed parts of the body. Any one who is sus- 
ceptible to such poisoning and knows that he has been 
exposed, should use, besides the local soap and water, 
a general hot bath, and should be sure that the possi- 
bly infected outer clothing is not again worn until 
thoroughly brushed and aired. 



CHLOASMA 577 

A strong solution of magnesium sulphate is perhaps 
one of the best local applications for the dermatitis 
when it develops. It relieves the itching and limits 
the inflammation. Oils or ointments containing ich- 
thyol may be used. Many people, however, are very 
susceptible to lead solutions unless they are very weak, 
and also if the skin is broken too much absorption of 
lead may occur. As just advised, the magnesum sul- 
phate solution is probably the best treatment. As soon 
as the acute inflammation is over, any simple talcum 
powder, or powdered corn starch, is very soothing to 
the skin. 

CHLOASMA 

The mechanism regulating pigment formation in the 
skin is entirely unknown. That there is such a mechan- 
ism is indicated by the disturbances of pigmentation 
which appear without any demonstrable cause, and 
which occur in association with pregnancy, with dis- 
eases of the suprarenal glands, and occasionally with 
various tumors in the abdomen and pelvis. These 
cases of chloasma associated with pelvic and abdominal 
conditions are vaguely explained as being due to dis- 
turbances of the abdominal sympathetic nervous sys- 
tem. They are undoubtedly due to disturbances of 
some mechanism in the abdomen and pelvis, but that it 
is the sympathetic nervous system is in large part a 
surmise. 

In the face of so obscure an etiology, there is no 
rational method of systemic treatment. The most that 
can be done is to make an effort to overcome such 
uterine and other pelvic or abdominal sources of irrita- 
tion as may be manifest. But such systemic treat- 
ment directed to the relief of chloasma is usually 
entirely futile. 

We are left to local methods of treatment, and the 
best that such treatment can do is to get rid of the 
pigment temporarily. The increased pigment in these 
patches is situated in the lower part of the epidermis, 
and this pigment can be removed by the use of appli- 
cations which cause deep exfoliation of the epidermis. 
This escharotic treatment is best referred to the skin 
specialist. 



578 USES OF BORIC ACID 

BORIC ACID IN SKIN DISEASES 

Boric acid according to Montgomery {Jour. 
A. M. A., 1915, lxiv, p. 883) has a very extensive use 
in skin diseases but is almost always used as an adju- 
vant. 

Acne. — An initiatory soaking with a hot boric acid 
solution is often of great benefit in the local treatment 
of acne. For this purpose it is desirable to apply the 
solution hot and to use a large quantity of it, so that 
the heat will be retained for a considerable time. Three 
heaping tablespoonfuls of boric acid powder are added 
to the usual quantity of water used in washing — 
about 3 quarts. This makes approximately a 3 per 
cent, solution. The patient should then sit, leaning over 
the bowl, and soak the face well with towels wrung out 
of the hot solution. As the solution grows cooler, 
more hot water may be added. It is often advan- 
tageous so to soak the face for ten or fifteen minutes. 
It softens the epithelium and acts as an excellent deter- 
gent, removing the grease and many of the micro- 
organisms, and decidedly increases the efficiency of a 
resorcin or sulphur application. 

Furuncle. — In the primary stage of active congestion 
in furuncles, Montgomery suggests that moist heat 
together with a nonirritating antiseptic are the topical 
therapeutic indications. These indications, he says, 
may be met by employing gauze dipped in hot satu- 
rated (4 per cent.) solution of boric acid, and envel- 
oping with oil silk to retain the moisture and the heat. 
This is similar to a poultice, but is not so good, as it 
is not so bland and does not retain the heat so well; 
it, however, is often sufficient, and is easier to apply. 
An admirable poultice for this purpose is made by 
mixing boric acid powder with starch paste. The 
preparation of this will be taken up later. 

Styes. — The stye is a form of furuncle of the eye- 
lid. It has been pointed out that styes may be related 
to seborrhea of the scalp. In the treatment of styes, 
Montgomery orders persistent bathing and soaking for 
half an hour twice a day with warm saturated solution 
of boric acid, and after each soaking the rubbing in 
of a salve of 1 per cent, red mercuric oxid in vaselin. 



BORIC ACID IN SKIN DISEASES 579 

Suppurative folliculitis of the vibrissae of the nares 
is another pyogenic affection in which boric acid may 
be employed with advantage. This folliculitis is a 
most tantalizing affection, and is often combined with 
cracking of the mucous membrane at the anterior angle 
of the nares, constituting one of the causes of red 
nose. These lesions may also furnish a convenient 
entrance for the streptococci. An efficient manner of 
treating this folliculitis is to set before the patient a 
tin cup of saturated solution of boric acid, kept hot 
by placing it over the flame of a spirit lamp. The 
patient takes pledgets of absorbent cotton, dips them 
in the hot solution, and pushes them into the affected 
nostril, repeating this during ten or fifteen minutes till 
the tissues are well softened, and the crusts softened 
and loosened. Calomel, 12 per cent, in vaselin, is then 
well rubbed in. This procedure may be repeated two 
or three times a day. Care must be taken both to soak 
thoroughly and anoint the fossa behind the nose tip, as 
these hollows are a favorite residence for germs in this 
affection. Epilation may or may not be necessary. 

Impetigo. — To remove the crusts in impetigo Mont- 
gomery applies to the lesions a boric acid starch poul- 
tice. The making of this poultice is a simple matter, 
but it is often the simple matters that are the most 
neglected. It is made in the following manner: 

Take ordinary, common, lump laundry starch and 
pulverize it. This pulverization is to be done before 
measuring. Dissolve one slightly heaping tablespoon- 
ful of the pulverized starch in two tablespoon fuls of 
cold water. Add to this one coffee cupful of boiling 
water, stirring rapidly until the mixture is a thick 
paste. To this paste add a tablespoonful of boric acid, 
free from lumps, and stir well until thoroughly mixed. 
Fold the warm jelly between layers of thin muslin or 
cheesecloth, and apply as hot as can be borne. 

A good poultice should not be too thin or it will 
dry, nor too bulky, or it will run ; it should be slightly 
less than a finger thick. In order to prevent the bor- 
ders drying and sticking to the surface, they may be 
greased with vaselin, oil or zinc oxid ointment. 



580 BORIC ACID IN SKIN DISEASES 

This poultice is not gummy like a linseed poultice, 
is cleaner looking and retains heat just as well. 
Besides the foregoing use, such a poultice has a mul- 
titude of applications, sometimes being employed hot, 
sometimes cold, as pointed out by Sabouraud. 

When, by means of this poultice, the crusts are 
softened and loosened, they may be gently removed. 
This removal is often best accomplished by rubbing 
in a salve containing an appropriate antiseptic, such 
as ammoniated mercury. The following ointment is 
an excellent one for the purpose: 

Gm. or C.c. 
IJ Ung. hydrargyri ammoniati . . 15 1 % ss 

Ung. zinci oxidi 30| Si 

M. Sig. : Use twice a day both to clean and dress the 
affected surface. 

The real efficient antiseptic in the above is the 
ammoniated mercury, a remedy familiar to every skin 
clinic in which naturally streptococcic infections are 
among the daily visitors. The 10 per cent, ointment of 
the Pharmacopeia, however, is too stimulating, and 
the zinc oxid ointment both dilutes it and modifies its 
asperity. 

As a general lotion for more widespread use in very 
scattered pyogenic infection of the skin, a saturated 
solution of boric acid in dilute alcohol serves admir- 
ably. It is harmless, it is clean and does not stain, 
and is not disagreeable in either appearance or odor, 
and because of the alcohol cutting the fat of the 
cutaneous surface, both the alcohol and the boric acid 
are permitted to act effectively as antiseptics. 

Perleche. — In this infection of the mouths of 
infants, pledgets of cotton wet in warm boric solution 
should first be industriously sopped into the corners of 
the mouth where there is cracking and a characteristic 
gray veil-like covering. If possible, they should be 
drawn across the corners of the mouth saddlewise and 
left there. After this the ointment of ammoniated 
mercury and zinc oxid above mentioned should be 
rubbed in, being careful that too much absorption does 
not occur. 



PICRIC ACID IN SKIN DISEASES 581 

Paronychia. — In paronychia or felon, both as an 
abortive measure and as an antiphlogistic antiseptic 
measure, a dressing of a combination of boric acid and 
liquor alumini subacetatis may do excellent service. 
A lotion is made as follows: 

Gm. or C.c. 

Ifc Liq. alumini subacetatis 30] 3 i 

Acid boric sol. sat 300| A3 x 

M. Sig. : Employ warm water to bathe the finger, and also 
as a wet dressing. 

Gauze soaked in this solution is wrapped about the 
finger, and then an amply fitting rubber finger-stall is 
drawn over it and retained by a not too tight bandage. 

Liquor alumini subacetatis is among the best of the 
mild antiseptics, and is gradually coming into favor in 
surgical clinics. It must be carefully prepared, and 
should be diluted about ten times. The water employed 
in its dilution is not an indifferent matter, as that con- 
taining carbonates throws down a heavy gelatinous 
precipitate of aluminum hydroxid. As the foregoing 
prescription is put up by a druggist* and with distilled 
water, this mischance is avoided. 

Montgomery believes that, used either alone or com- 
bined with other powders, boric acid is very valuable 
in many discharging diseases of the skin. An excel- 
lent powder is made of equal parts of boric acid and 
talc, or of equal parts of starch, zinc oxid and boric 
acid. 

The boric acid ointment of the Pharmacopeia con- 
tains about 8 per cent, of boric acid, while Lister's 
ointment is much stronger — about 16 per cent. Boric 
acid ointment is an excellent nonirritating preparation 
with a multitude of uses. It is an ointment that, more 
generally than any other, is well prepared, and this is 
a point of importance when the druggist who is to put 
up a prescription is not known, as ointments are often 
wretchedly made. In seborrheic conditions this oint- 
ment will sometimes agree when those more usually 
employed fail. 

PICRIC ACID IN SKIN DISEASES 

Wilcox {Archives of Pediatrics 30:877, 1913) 
believes that as an aid in the relief of discomfort in 



582 PICRIC ACID IN SKIN DISEASES 

skin lesions as well as in their cure, picric acid has 
proved its worth. The drug is safe and easy to han- 
dle, the only drawback being the permanent staining 
of everything with which it cc*mes in contact. 

Eczema. — Better results were obtained in the acute 
than in the chronic eczemas; most striking was the 
improvement seen in the acute cases having profuse 
exudation, excoriation and crusting. In the milder 
cases an aqueous solution painted on several times 
daily and allowed to dry was used, while in the more 
severe cases wet dressings of picric acid were applied, 
held in place by a facial mask. Lessening of the itch- 
ing and pain attendant on the inflammatory condition 
was almost immediate. Reduction in the serous exu- 
dation and softening of the crusts were equally prompt. 
Improvement in the induration was rapid, as was the 
subsequent epithelialization. Such a rapid relief of the 
suffering attendant on this distressing condition was 
not obtained by any other means. Picric acid alone 
was not as efficacious in the subacute and chronic 
types of the disease; it was found, however, that the 
curing of the lesions was hastened materially by treat- 
ment initiated by two or three days' application of the 
picric acid solution. The effectiveness of the usual 
ointments, containing zinc, tar, salicylic acid, calomel, 
mercury, etc., was much greater than without this 
preliminary treatment. 

Intertrigo. — Intertrigo was treated with picric acid. 
The solution was painted on the surfaces of the skin 
involved and they were kept from coming in contact 
by thin layers of absorbent cotton. In the more 
severely infected cases wet dressings were used. Cures 
were effected in about half the time taken on similar 
cases treated with ichthyol solutions. The use of pic- 
ric acid in intertrigo was so satisfactory that a bottle 
of the aqueous solution is now part of the regular 
equipment of the dressing carriage, and the nurses, in 
the routine of changing the babies' napkins, apply it 
whenever the buttocks appear red or irritated. 

Erysipelas. — Results in the treatment of erysipelas 
were not uniformly successful. In certain ways they 
were, however, more satisfactory than the results 
obtained by the use of any other method. The dis- 



PICRIC ACID IN SKIN DISEASES 583 

comfort and pain attendant on the condition were 
relieved more quickly and the edema disappeared 
rapidly. In several cases desquamation in cast-like 
masses followed the use of picric acid, leaving a 
healthy normal skin beneath. A reduction in the tem- 
perature of these patients was the rule, occurring with 
or without marked improvement in the local condition. 
Herpes Labialis. — In herpes labialis a more rapid 
drying up of the lesion and fewer extensions of the 
trouble were obtained with picric acid than. with any 
other method used. 



SYPHILIS AND DISEASES OF THE 
GENITOURINARY TRACT 



SYPHILIS 

The finding of the organism of syphilis, the Spiro- 
chete ta pallida, in the initial lesion is, of course, the 
conclusive evidence of syphilitic infection. Antiseptics 
applied, especially mercurials, make the finding of 
Spirochaeta pallida difficult or almost impossible. No 
mercurial dressings, or better still, no antiseptics, 
should be applied to any lesions until the examination 
for Spirochaeta pallida has been made, and if any have 
been used, it should be made a routine to irrigate thor- 
oughly with physiologic sodium chlorid solution and to 
apply a wet dressing of the solution for twelve hours or 
more before examining for Spirochaeta pallida. The 
primary lesion should be wiped clean with a sponge wet 
with physiologic saline solution. From the clean 
oozing surface which remains a drop of serum is taken 
and placed on a slide. The organisms may then be 
sought in the hanging drop by means of dark field 
illumination or in a stained specimen. The organism 
is a regular spiral organism of from 6 to 15 microns 
in length, and has from 3 to 25 turns. The average 
length is about twice that of a # red blood corpuscle. 
The Wassermann test should be made in all suspected 
cases. If a Wassermann test is positive it should 
immediately be confirmed by another test perhaps 
made by another laboratory specialist. Usually the 
test -is negative during the first week of the disease. 
If, however, the spirochetes can be demonstrated in 
the primary lesion, treatment should not be delayed. 
If the lesion is clinically chancre Wassermann tests 
should be repeated at intervals of a week for at least 
a month to see if a positive will not be secured. 

EARLY TREATMENT 

The patient should be instructed regarding the 
observance of good general hygiene. A nutritious 
simple diet, total abstinence from alcohol, a proper 






PRIMARY LESION IN SYPHILIS 585 

amount of fresh air and physical exercise are in this, 
as in all disease conditions, important factors in the 
treatment. 

THE CARE OF THE PRIMARY LESION 

It is no longer considered good treatment to cauter- 
ize a chancre. Ordinary cleanliness and protection 
should be used. When the location of the chancre is 
such that physical deformity will not accompany its 
excision, this may be considered. Until the search 
for the spirochete is completed the lesion should be 
merely covered with a dressing moistened with physio- 
logic saline solution. After a positive diagnosis is 
made the chancre may be treated with a 33 per cent, 
calomel ointment applied twice daily for a week by 
inunction; in the interval it may be covered with 
gauze and some bland ointment. Reasoner has shown 
that the spirochete is killed promptly by a lather of 
soap. 

ARSPHENAMIN AND NEOARSPHENAMIN 

The use of arsphenamin and neoarsphenamin — 
names adopted by the Federal Trade Commission for 
drugs formerly known as salvarsan and neosalvarsan — 
early in the disease is productive of an early disap- 
pearance of external lesions and if sufficiently early 
will often prevent the appearance of such secondary 
signs as the eruption, sore throat, alopecia and sys- 
temic disturbances of secondary syphilis. The dose 
of arsphenamin should be graduated to the weight of 
•the patient. Ordinarily for an adult male it is 0.4 to 
0.6 gm. of arsphenamin given at five day intervals 
until three doses are taken ; after that at intervals of 
a week for five more doses, making a total of eight 
doses of arsphenamin in a little more than six weeks. 
This is then followed with a treatment with mercury. 
After a rest period of six or eight weeks it is desirable 
to repeat this course of treatment regardless of the 
results of the Wassermann test. The patient should 
then be watched, having frequent Wassermann tests, 
for any evidence of relapse. 

The arsphenamin should be given preferably intra- 
venously, although this drug properly prepared has 
also been given intramuscularly, subcutaneously and 



586 INJECTION OF ARSPHENAMIN 

even orally. The technic should be extremely careful. 
Before giving the drug the urine of the patient should 
be examined for evidence of kidney irritation. The 
patient's stomach should be empty. He should remain 
quiet for the remainder of the day, and should take 
no food until the next morning after the injection. 
As reactions frequently occur and as these are usually 
treated with injection of from 5 to 10 minims of the 
1 : 1,000 solution of epinephrin, it is sometimes advisa- 
ble to inject a small dose of epinephrin before starting 
the treatment.- It has also been suggested that the 
giving of liberal doses of sodium bicarbonate before 
injection of the salvarsan is a fairly efficient pre- 
ventive of reactions. 

The injection of this drug intravenously is a minor 
operative procedure. It should be carried out with 
strict asepsis. The apparatus, the physician's hands, 
the site of injection, should all have been surgically 
prepared and be surgically clean. The drug is dis- 
solved in 50 c.c. of hot water, yielding a strong acid 
solution, which is then neutralized and diluted before 
injection. A 15 per cent, solution of sodium hydroxid 
is added, drop by drop, until the arsphenamin is pre- 
cipitated and again dissolved, at which point the solu- 
tion will be slightly alkaline. The mixture should 
not be shaken too vigorously, for fear of oxidizing 
the arsphenamin, which is a relatively unstable drug. 
The solution is then filtered through wet sterile cotton 
into a graduated container. Water is then added to 
produce the proper dilution. In the meantime, the 
patient's arm has been cleaned, a tourniquet applied 
to engorge the veins, and the vein entered with the 
needle. The adapter fitted to the tube from the grad- 
uate containing the drug is then fitted to the needle 
and the solution allowed to flow in gradually under 
very low pressure. 

The neoarsphenamin is more soluble and is most 
frequently injected by dissolving the contents of the 
ampule in 10 c.c. of freshly distilled water, at room 
temperature, directly in the barrel of a large syringe 
and then injecting directly into the vein. The solution 
of this drug is neutral and requires no special treat- 



TOXICITY OF ARSPHENAMIN 587 

ment. This drug is generally believed to be of less 
potency than any of the preparations of arsphenamin. 

TOXICITY OF ARSPHENAMIN 

Schamberg, Kolmer and Raiziss, after extensive 
experimental studies of arsphenamin preparations, 
find that failure to neutralize solutions of arsphenamin 
with alkali leads to an increase in toxicity ; a moderate 
excess of alkali does not increase the toxicity, but may 
have untoward effects. Sterile freshly distilled water 
appears to possess advantages over sterile stale or non- 
distilled water, although the difference was not pro- 
nounced. The toxicity of the arsphenamin in alkaline 
solution increases rapidly, due to oxidation, and the 
drug should be used promptly after its preparation. 
All of the preparations of arsphenamin now being 
sold in the United States are subjected to biologic 
toxicity tests both by the manufacturers and by the 
Hygienic Laboratory of the United States Public 
Health Service, and if the physician's technic is good 
they may be used with confidence. 

Martin (Jour. A. M. A. 74: 1218, 1920) has analyzed 
some of the factors responsible for these reactions. 
One should note any departure from the normal lemon- 
yellow color of the brand of arsphenamin being used, 
and then immerse the ampule in 95 per cent, alcohol 
for fifteen minutes to detect obscure cracks. Cracked 
ampules or ampules that contain discolored arsphena- 
min are to be rejected, the substance having become 
oxidized. One is further directed to prepare individual 
solutions, and when this is not practical, not to prepare 
more solution than can be disposed of within half an 
hour. Using the syringe-container method, and allow- 
ing six minutes for each 0.5 gm. of arsphenamin in 
solution, limits the number of ampules that may be 
used at one time to five. The sooner the solution is 
disposed of, the less danger of oxidation. 

"Using the directed technic for one brand of ars- 
phenamin while preparing the solution of another will, 
in some cases, cause reactions. Salvarsan (Metz) calls 
for freshly distilled water of not more than room tem- 
perature; diarsenol requires warm, freshly distilled 
water; and arsenobenzol is to be dissolved in boiling 



588 TOXICITY OF ARSPHENAMIN 

hot, freshly distilled water. Salvarsan becomes oxi- 
dized when dissolved in hot water. The directions call 
for freshly distilled water or physiologic sodium chlorid 
solution, prepared from chemically pure sodium chlorid 
— not from table salt. It is directed that normal 
sodium hydroxid (4 per cent.) or 15 per cent, solution 
be used to neutralize and alkalize arsphenamin in solu- 
tion. Faulty preparation with impure or altered 
sodium hydroxid, or contaminated distilled water, may 
cause reactions. 

"Neutralizing arsphenamin, which is a dihydrochlorid 
salt, requires a definite amount of sodium hydroxid 
to render it slightly alkaline and suitable for use. A 
large percentage of reactions resulting when technic 
is not strictly followed are due to hypo-alkalization, 
while hyperalkaline solutions, due to faulty measuring 
of sodium hydroxid solution, cause reactions at times. 
A graduated pipet or buret is recommended to be used, 
the certainty being a normal-sized drop and accurate 
measure. Arsphenamin is precipitated as a. basic salt 
by sodium hydroxid; it requires a definite amount 
to redissolve the precipitate, changing the basic salt 
to a monosodium salt, the solution being just alkaline 
to litmus paper. On further addition of a definite 
amount of sodium hydroxid, a disodium salt is formed 
which is completely soluble in water. The bask: pre- 
cipitate and monosodium salt will cause reactions, the 
disodium salt in solution, properly diluted and filtered, 
being suitable for use." 

All manufacturers agree that solutions should be of 
room temperature. Injecting too cold solutions into 
the circulation will induce chill reactions. Too rapid 
giving of the solution, particularly in high cencentra- 
tion, will cause reactions in some instances. One is 
advised not to give more than 0.1 gm. of drug (30 c.c. 
of solution) in two minutes; the gravity method is the 
one advised; the rate of flow is controlled by the size 
of the needle (No. 18 or 20 B. & S. gage) and the 
height of the column of fluid. The syringe-container 
method is favored by many operators, and while not 
as "fool proof" as the gravity method, an expert can 
handle difficult work with greater precision. 



MERCURY IN SYPHILIS 589 

Giving too large a dose of arsphenamin at the begin- 
ning of a course of treatment accounts for some reac- 
tions. Lack of preliminary preparation for treatment 
— a laxative the night before, and a light breakfast 
four or five hours before operation — is sometimes a 
cause. Every patient should be given a careful phys- 
ical examination to determine organic or functional 
impairments, as findings may limit or contraindicate 
arsphenamin treatment. When two or more reactions 
occur from a multiple ampule solution, in the majority 
of instances the fault will be found in the technic of 
preparing the solution, and the usual cause will prob- 
ably be hypo-alkalinity. 

FACTORS ATTRIBUTABLE TO THE PATIENT 

Both arsphenamin and the technic in preparing its 
solution having been excluded, factors attributable to 
the patient are to be considered. Tissue susceptibility 
to arsphenamin medication includes allergic idiosyn- 
crasy, an inherited dominant susceptibility to arsphen- 
amin medication; anaphylaxis, protoplasmic sensitiza- 
tion from repeated doses ; blood synthesis reactions, in 
which arsphenamin becomes altered or precipitated 
from causes not understood, or ascribed to excess of 
carbon dioxid in the blood, or faultily prepared ars- 
phenamin solutions ; and the nitritoid reaction, ascribed 
to the action of arsphenamin in destroying spirochetes 
and liberating large quantities of bacterial protein to 
whch the tissues have become sensitized. The Herx- 
heimer reaction is attributed to the stimulating activity 
of nonsterilizing doses of arsphenamin. 

MERCURY 

The inunction treatment is an efficient method of 
attacking the disease if it is done in an efficient man- 
ner. As a general rule the patient cannot be trusted to 
conduct this treatment alone. A course of inunction 
treatments may consist of 20, employing 4 grams (a 
dram) of the official mercurial ointment, rubbed well 
into the different parts of the body, once a day, the 
treatment lasting at least 15 minutes. A turkish bath 
or "body bake" at least once a week is advisable. 



590 MERCURY IN SYPHILIS 

Another method of administering mercury, probably 
most popular in recent years, is that by intramuscular 
injection. The most favorable site is usually the 
gluteal region. The lower part of the buttock should 
be avoided in order that the patient may sit without 
undue discomfort; the center of the gluteal region 
should be avoided because of the danger of puncturing 
gluteal vessels or the sciatic nerve. Of course the two 
sides should be used alternately in giving a series of 
injections. 

The best syringe for these injections is one made 
entirely of glass, of small caliber, and graduated to 
fractions of a minim, such as is made for tuberculin 
injections. The needle should be from iy 2 to 3 inches 
in length. Steel needles are much cheaper than those 
of iridoplatinum, but are likely to be corroded by solu- 
ble mercurial salts. 

The fluid is drawn into the syringe, and any air 
bubbles carefully expelled. Then the skin having been 
properly cleansed, the needle is thrust through it in a 
perpendicular direction so as to reach the required 
depth at a single stroke. Next assure yourself that 
the point of the needle does not lie in a vein, by 
detaching the barrel and watching the lumen for a 
moment. If blood flows through the needle, make 
another puncture; otherwise replace the syringe and 
proceed with the injection. It is not necessary to mas- 
sage the injected mass. The most careful practice is 
to make the injections with the patient lying down. The 
dressing of the puncture is necessary only when 
bleeding occurs. 

The preparations of mercury used in this way 
include both soluble and insoluble salts. The most 
useful soluble salts are the chlorid and the succinimid. 
The average dose of the chlorid and succinimid is 0.015 
gm. or % grain. The insoluble salts most frequently 
used are the basic salicylate, calomel and gray oil, the 
latter being an emulsion of metallic mercury in an oily 
vehicle. It is most important that all these substances 
be pure and neutral. 

The drugs may be purchased from any good pharma- 
ceutical house in ampules ready for injection. Several 
approved preparations are listed in New and Nonofficial 
Remedies. 



IODIDS IN SYPHILIS 591 

Injections of soluble salts should be used when rapid 
mercurialization is required. They may be used at the 
beginning of treatment. The insoluble salts are indi- 
cated in the routine treatment of most cases. Calomel 
is usually more effective in urgent cases, but it causes 
too much pain to be used in ordinary cases, in which 
the salicylate and the gray oil are preferable. 

In beginning treatment it may be necessary to give 
an injection every day for a few days; but afterward 
a weekly injection will be sufficient. 

Among the disadvantages of this form of treatment 
should be noticed the fact that it is more or less painful. 
With the soluble salts the pain begins at once and lasts 
for from 1 to 6 hours. With insoluble preparations 
it begins within an hour, and lasts from 2 to 5 days. 
The pain is most severe after calomel, and least so 
after gray oil, which is often entirely painless. 

Hard masses of exudates, known as nodes, some- 
times form about the injected mass. These often 
retain a portion of the injected fluid, which may subse- 
quently be suddenly absorbed. . ' 

Embolism sometimes results from the injection of 
the fluid into a vein. Although this has rarely, if ever, 
proved fatal, it should be avoided. Abscesses rarely 
occur if the injections are properly administered. 

Whatever method of administering mercury is 
adopted, certain general hygienic rules must always be 
observed. The teeth must be put into good condition 
and the mouth must be kept clean. Chewing tobacco 
must be absolutely interdicted. Moderate smoking 
may be allowed to those who are accustomed to the use 
of tobacco, unless some special condition renders it 
advisable to discontinue its use entirely. 

IODIDS 

Iodids are used in tertiary syphilis chiefly. While 
the iodid of potassium is the salt most generally used, 
the sodium iodid is perhaps preferable, since the 
sodium element is not as debilitating to muscle tissue 
as is the potassium. This is especially true of the 
cardiac muscle. Hence when large doses must be 
given, or when it must be given for a long time, the 



592 IODIDS IN SYPHILIS 

iodid of sodium should be preferred. This salt also 
sometimes seems less likely to disturb the stomach. 

The symptoms of iodism should be avoided if possi- 
ble. These symptoms are coryza, frontal headache, 
reddening of the eyelids, a strong, metallic taste in 
the mouth, sometimes a profuse flow of saliva and 
gastric indigestion. It is unimportant whether the 
iodid is ordered largely diluted or in saturated solu- 
tion, but it should never be ordered in any syrupy, 
nasty mixture. It is preferably administered in milk 
or in an alkaline water. It is generally best taken 
after a meal, theoretically best an hour after meals, 
as it slightly inhibits digestion. When an iodid is 
administered the yellow iodid (the protoiodid) of 
mercury should not be the salt selected for simulta- 
neous administration, as it is likely to be chemically 
changed into the biniodid (red iodid) of mercury, 
which salt would then be present in a poisonous quan- 
tity. The following prescriptions may be used : 



Gm. 



H Sodii iodidi 25 

Aquae destillatae, q. s. ad 
saturandum 



3 viiss 
or 
q. s. ad sat. 



M. Sig. : Five drops with milk or water, three times a day, 
after meals. The dose should be gradually increased until 
the amount given is deemed sufficient. 

Each minim of this solution represents a grain of the drug. 
The statement frequently made that a drop of saturated solu- 
tion of potassium or sodium iodid represents a grain of the 
drug is apt to lead the physician into error, as the size of a 
drop varies with the size and nature of the container from 
which it is dropped. 

Or: 

Gm. or C.c. 

B Potassii iodidi 10| or 3 iiss 

Aquae 100| A3 iii 

M. Sig.: One-half a teaspoonful, in milk or water, three 
times a day, after meals. 

The iodids have been given in enormous doses, espe- 
cially where gumma of the central nervous system has 
been diagnosed. It is a question whether such large 
doses are justifiable and even whether such large doses 



IODIDS IN SYPHILIS 593 

are of advantage. It is probable that ordinary fair- 
sized doses can do as much chemical and biologic good 
as any dose however large in causing resorption of 
connective tissue formations, the blood and cells being 
able to absorb and utilize only a certain amount of 
iodin. In other words, enormous doses are illogical 
and are probably rapidly passed out of the body by the 
excretions. 

jfobling and Peterson (Journal A. M. A., Nov. 28, 
1914, p. 1931), say: "Clinical experience teaches us 
that in the tertiary stage of syphilis iodin is almost a 
specific in bringing about the amelioration of symp- 
toms, and the disappearance of lesions, and yet little 
is known concerning the means by which these results 
are obtained. 

"As experimental work and clinical observations have 
demonstrated that the iodids do not destroy the infect- 
ing organism, we must assume that the results obtained 
are due to the power the iodids possess of causing 
resolution of the lesions present. That this actually 
occurs will be attested to by every clinician of experi- 
ence. It is due to the fact that the unsaturated fatty 
acid radicals which inhibit autolysis have become satu- 
rated with iodin. As soon as this occurs, the ferments 
which are present, or which may be brought in, become 
active, autolysis takes place, and the necrotic tissue is 
absorbed. Here, also, the local action of the ferments 
is made less difficult by the reduction of the anti- 
enzyme in the circulating blood. It must be borne in 
mind that the iodids are not as effective in the earlier 
stages of syphilis, when necrosis of tissue is not so evi- 
dent. 

"If the above interpretation of the action of iodin is 
correct, it gives the clinician a rational idea of what 
he is accomplishing when he gives iodids to a patent 
in the tertiary stage of syphilis. According to this 
view, iodin neutralizes the action of the agents which 
prevent resolution and absorption of the diseased or 
necrotic tissue, and at the same time lays bare to the 
action of the real germicidal agent the infecting organ- 
ism which previously had been protected by the 
necrotic tissue. With the exposure of the infecting 



594 CARE OF THE MOUTH IN SYPHILIS 

organism, such agents as mercury and salvarsan would 
be much more effective." 

CARE OF THE MOUTH 

During the mercurial treatment the patient should 
drink plenty of water to promote the activity of all the 
organs of excretion. The mercury will probably soon 
cause sufficient or even perhaps too frequent move- 
ments of the bowels. The care of the mouth, teeth 
and gums is important, and the patient cannot be too 
carefully instructed in this matter. Any alkaline wash, 
or, if there are any erosions, peroxid of hydrogen 
applications, or a mouth wash of alcohol one part and 
water three parts, or a potassium chlorate mouth wash, 
and occasionally tannic acid washes and gargles are 
useful. Ulcerations in the mouth and throat will often 
heal rapidly after one or two applications of a 25 per 
cent, solution of nitrate of silver. Without ulceration 
in the mouth and throat the mucous membrane may 
be kept healthy by a thorough cleaning of the teeth 
two or three times daily, and the cleansing of the 
mouth and throat with alkaline solutions. 

An excellent dentrifice has been suggested by Fantus : 

LIQUID DENTIFRICE 

Gm. or C.c. 
fy Castile soap, dried and granulated 6 00 

Benzosulphinid 20 

Basic fuchsin 002 

Oil of cassia 50 

Oil of peppermint 50 

Oil of cloves 1 00 

Alcohol 75 00 

Water to make 100 00 

A few drops added to water to be used as a mouth wash. 

It will be noted that, excepting for the volatile oils 
present, antiseptics and disinfectants are conspicuous 
by their absence. As is well known, it is impossible to 
dsinfect the mouth. Mere bacteriostatic (germ growth 
inhibitive) influence can be of value only as long as the 
agent is present ; and the time that one is willing to keep 
the mouth full of fluid is limited. The chief virtue of 
mouth wash preparations lies in their esthetic qualities : 



SYPHILIS OF THE NERVOUS SYSTEM 595 

their pleasant appearance, odor and taste, which make 
one use them with a greater -degree of pleasure and 
therefore more faithfully. 

The patient should be thoroughly instructed as to the 
danger of his infecting others and the manner of such 
infection — as by napkins, towels, drinking cups, spoons, 
forks, or kissing. Such instructions should be most 
explicitly given if there are mucous patches in the 
throat. 

SYPHILIS OF THE NERVOUS SYSTEM 

Swift and Ellis (Archives of Internal Medicine, Sep- 
tember, 1913) suggested what is known as the auto- 
serosalvarsan method of treating syphilis of the ner- 
vous system. Briefly the method consists in injecting 
salvarsan intravenously, waiting one hour, withdraw- 
ing 40 c.c. of blood, allow it to coagulate, then cen- 
trifugalize. The following day pipette off 12 c.c. of 
serum, and dilute with 18 c.c. of normal saline. Heat 
to 56 C. for one half hour. After lumbar puncture 
withdraw the spinal fluid until a pressure of 30 mm. 
is reached. The barrel of a 20 c.c. all glass syringe 
is connected to the needle by means of a rubber tube 
about 40 cm. long. The tubing is then allowed to fill 
with cerebrospinal fluid, so that no air will be injected. 
The serum is then poured into the syringe and allowed 
to flow slowly into the subarachnoid space by means 
of gravity. At times it is necessary to insert the 
plunger of the syringe to inject the last 5 c.c. of fluid. 

In addition to the Swift-Ellis method there have 
been used serum to which small quantities of salvarsan 
have been added; neoarsphenamin in small quantities 
and weak concentration and mercurialized serum. 
With the former two methods severe reactions have 
occurred and patients have developed bladder paraly- 
sis and in some cases a fatal issue was the outcome. 
The danger of injecting mercurialized horse serum 
lies in the possibility of producing a general anaphy- 
lactic state. Fordyce, Sachs, Barbat, Corbus and many 
others are inclined to believe that just as good results 
can be achieved by intensive intravenous treatment 
and spinal treatment. It has also been suggested that 
simultaneously with the injection of the arsphenamin 



596 ACUTE GONORRHEA 

in the blood a quantity of spinal fluid be withdrawn in 
order to cause more of the drug to pass into the spinal 
fluid from the blood by whatever physiologic process 
this takes place. 

ACUTE GONORRHEA 

While, theoretically, the most sensible treatment in 
this unfortunate common disease would be to place 
the patient in bed, on a milk diet combined with bland 
alkaline drinks and free catharsis, it is obviously 
impossible, in the majority of instances, to carry out 
such treatment. Consequently it should be aimed to 
get as near as possible to such general treatment. 

GENERAL TREATMENT 

Exercise. — The patient should be forbidden all vio- 
lent exercise. Running, swimming, dancing, gymnas- 
tics, and extreme exertion of any kind should be for- 
bidden. 

Suspensory. — Rest is obtained by the wearing of a 
suitable suspensory bandage. The penis should be 
held toward the abdomen. Ordinary suspensory ban- 
dages do not do this. The patient should be com- 
manded to avoid sexual intercourse and all sexual 
excitation. 

Diet. — All substances which may bring on constipa- 
tion or excite the generative organs should be forbid- 
den. Alcohol, coffee, tea, highly spiced foods and 
condiments, very acid or salty dishes, and various 
shellfish should be forbidden The use of tobacco in 
small amounts by those habituated to its use may be 
continued, but excess is certainly contraindicated. 

Cleanliness. — The patient should be instructed to 
maintain scrupulous cleanliness. The penis should be 
covered with a clean dressing after each micturition. 
The patient should avoid frequent handling of the 
genitalia. After such handling the hands should be 
washed thoroughly, and the eyes should not be touched 
because of the danger of gonorrheal conjunctivitis. 

Fluids. — The patient should drink freely of water. 
One of the best methods of diminishing pain during 
micturition is to increase largely the quantity of urine. 



ACUTE GONORRHEA 597 

It may be necessary to influence the reaction of urine, 
making it either alkaline or acid as conditions indicate. 
The best alkalinizers of the urine are the well known 
potassium salts, the acetate, bicarbonate and citrate, 
and every physician has his favorite combination of 
these drugs. Any one of these salts is efficient if given 
in sufficient doses, though many physicians think a 
combination is better. The acetate is perhaps the most 
active alkali of the three, the bicarbonate the most 
disagreeable to take, and the citrate the pleasantest. 

The urine is more readily rendered alkaline by the 
administration of the alkali directly after a meal, at 
which time the urine is the nearest to neutral on 
account of the production of hydrochloric acid in the 
stomach. The amount of an alkali that should be 
administered cannot be determined except by examina- 
tion of the urine; in other words, if the object is to 
render the urine alkaline, enough should be given to 
cause that condition. Any of the following combina- 
tions are satisfactory: 

Gm. or C.c. 

R Potassii citratis 401 or 3 ii 

Aquae 200| S viii 

M. Sig. : Two teaspoonfuls, in water, three times a day, 
after meals. 

[The water may be flavored with an aromatic, as pepper- 
mint, spearmint, wintergreen, or cinnamon, if desired.] 

It will often be necessary to administer the above 
dose more frequently than three times a day. Also, as 
an adjunct, it is sometimes advisable to have the patient 
drink several glasses of artificial or natural vichy, or 
some other alkaline water, during the day. 

Or: 

Gm. or C.c. 
Ifc Potassii acetatis 

Potassii bicarbonatis aa 10 3 iii 

Potassii citratis 20 or 3 vi 

Aquae cinnamomi 200| 3 viii 

M. Sig.: Two teaspoonfuls, in water, three times a day, 
after meals. 

Alkalies should not be pushed long if there is con- 
siderable mucus coming from the bladder, or if there 
is bladder irritability, for it must be remembered that 
the bladder mucous membrane is accustomed to an acid 



598 URINARY ANTISEPTICS 

secretion, and a continuous alkaline urine sooner or 
later causes irritability of the neck of the bladder, fre- 
quent micturition and even tenesmus. Also, if the 
urine becomes at all ammoniacal, the irritation of the 
bladder is made worse by alkalies, and the likelihood 
of deposits in the bladder is increased. 

URINARY ANTISEPTICS 

To render the urine antiseptic there are no better 
drugs than salol (phenylis salicylas) or hexamethylen- 
amin. 

As soon as the first acute symptoms are over, the 
alkali should be stopped, as it is not well for a healthy 
condition of the mucous membrane of the bladder to 
keep the urine alkaline for any considerable time. At 
this time it seems well to begin the administration of 
salol or hexamethylenamin, as thought best. If there 
is any irritation of the kidneys, salol, on account of 
one of its decomposition products being phenol, should 
not be used, phenol being irritant to the kidneys. If it 
is administered, it is well given as follows : 

Gm. or C.c. 
ty Phenylis salicylatis 6\ or 3 iss 

Fac capsulas siccas, 20. 

Sig. : A capsule every four hours. 

Hexamethylenamin, to be effective, must reach an 
acid medium, or its formaldehyd will not be released 
and its antiseptic action will be nullified. It may be 
given in a dosage of 5 to 10 grains three or four 
times a day in half a glass of water. 

COPAIBA AND SANTAL 

These drugs have long been used in gonorrhea for 
their action on the mucous membrane of the genital 
tract. They are indicated apparently for subacute and 
chronic gonorrhea rather than for the acute condition. 
As soon as posterior urethritis has developed, which 
occurs in the majority of cases of gonorrheal urethritis, 
one of the balsams is indicated, unless there is vesical 
irritation, as shown by great frequency of urination 
with small amounts of urine passed. Santal oil seems 
to be one of the best preparations and may be admin- 
istered as follows : 



LOCAL TREATMENT IN GONORRHEA 599 

B Capsulas olei santali flexibiles. .aa HI x 

No. 25. 
Sig. : A capsule three times a day, after meals. 

If there is no diminution in the amount of pus in 
the second glass of the two-glass test, and there are no 
symptoms of overaction of santal wood (viz., no pains 
referred to the ureters, or lumbar pains, and no special 
indigestion), two of these capsules three times a day 
may be taken. 

It should be emphasized that no patient with gonor- 
rhea can be well treated unless at each office visit he 
passes urine, that has been retained for at least three 
hours, into two glasses, he dividing the amount as 
nearly equally as his judgment permits. The washout 
from the urethra can thus be examined in the first 
glass, and the urine from the bladder and posterior 
urethra be examined in the second glass, and the con- 
clusions thus arrived at will many times decide the 
treatment that is needed. 

All balsam treatment may be stopped as soon as the 
posterior urethritits is cured. If, on the other hand, 
the posterior urethritis does not improve, the balsam 
may be increased in amount, or, if the posterior ure- 
thritis tends to become chronic, local posterior urethral 
treatment is indicated. It is also wise to demonstrate 
to the patient that, although the anterior urethral dis- 
charge may have ceased, he is not well until the -pos- 
terior urethra is healed. 

If it is preferred to use hexamethylenamin as a 
bladder and posterior urethra germicide treatment 
(and if the bladder becomes actually infected there 
probably is no better treatment), it may be given as 
follows : 

Gm. or C.c. 

B Hexamethylenaminae 6\ or 3 iss 

Fac chartulas, 20. 

Sig. : A powder, in a glass of water, four times a day. 

LOCAL TREATMENT 

The local treatment of gonorrhea involves the ques- 
tion of irrigations or injections. American genito- 
urinary specialists do not, in general, believe that 
irrigation is often indicated in anterior urethritis. It 
certainly appears not justifiable to give any great pres- 



600 LOCAL TREATMENT IN GONORRHEA 

sure to the delicate urethral membrane, as occurs by 
any irrigation method. Such irrigations may not only 
force the gonococci into deeper tissues as well as into 
the posterior urethra and perhaps bladder, but may so 
injure the mucous membrane as to cause long pro- 
tracted chronic inflammation and strictures. 

On the other hand, many times injections are badly 
done and lead to complications, suclr as prostatitis, 
cystitis and vesiculitis. To avoid these accidents the 
patient should not be given any syringe which holds 
more than 5 or 6 c.c. The patient should urinate 
before the injection. The meatus and glands should 
be washed and the fluid injected first should be allowed 
to run out. The patient then reinjects, closes the 
meatus, holds the fluid five minutes and then allows it 
to run out. 

The number of substances used for such injections 
is legion; chief, however, are silver nitrate and the 
organic silver preparations. Silver nitrate is used in 
a strength of 1 : 1,000. 

The silver compounds that may be used for this pur- 
pose are albargin, argentamin, argonin, argyrol, hego- 
non, novargon, protargol, sophol, cargentos, collargol 
and electrargol. All of these preparations are included 
in New and Nonofficial Remedies. The strength of 
the solution used varies with the preparation, argyrol 
from 5 to 20 per cent., protargol, 1 to 2 per cent., etc. 

The patient, as has been stated, should be carefully 
instructed first how to pass the urine and then how to 
use the syringe and how to retain the fluid. The 
length of time that he should retain it depends on the 
length of time that there is burning after the injec- 
tion has been evacuated. If the burning lasts a con- 
siderable time, the injection should be retained a 
shorter time. Unless there is a contraindication of 
much pain and burning, the retention of the silver 
solution for five minutes, and perhaps longer, is cer- 
tainly more likely to allow the germicide to penetrate 
more deeply. 

The injection may be used every three hours for the 
first twenty-four hours, and every four hours there- 
after. Every fourth day at least a smear of the dis- 
charge should be examined for the presence of gono- 



IRRIGATIONS IN GONORRHEA 601 

cocci. As they diminish in number the strength of the 
fluid is reduced and the frequency of its injection is 
diminished from four times daily to only twice daily. 

After the organisms have disappeared from the dis- 
charge for from three to seven days the injection is 
reduced to once a day, and from five to ten days later 
it is discontinued altogether. 

This frequent injection of the urethra would seem 
a little strenuous for the patient, and might need to be 
modified if it had caused much swelling and inflam- 
mation. As mentioned under the section on physical 
therapy, hydrotherapy in the form of hot applications 
and hot sitz baths may give relief if much inflamma- 
tion or irritation is present. 

IRRIGATIONS 

This method of treatment is more common on the 
continent than in this country. The number of drugs 
used for this purpose also embraces almost every drug 
of antiseptic nature in the pharmacopeia and elsewhere. 
According to Luys the chief and only contraindication 
is an acute local painful condition. Among the drugs 
used the principal ones are the silver salts, mercurial 
salts, potassium permanganate and bismuth salts. 
Very dilute solutions should be used at the start. The 
water should be warm, sterile water. The technic of 
giving such irrigations is difficult, though simple, and 
should be thoroughly understood before it is attempted. 
The solution is placed in an irrigation douche vessel 
which is fixed at a height of from three to five feet 
above the patient. The cannula is attached to a long 
tube leading from this vessel and there should be a 
stopcock to control the flow. The patient urinates, and 
lies prone. The genitalia are cleaned with an antisep- 
tic solution and a basin is placed to catch overflow. 
The glans is held with the left hand and the meatus 
held apart. The cannula is introduced. At first the 
anterior urethra is irrigated. The cannula being with- 
drawn and the fluid allowed to run out. The cannula 
is again introduced, the meatus closed against it and 
the patient instructed to bear down as though to uri- 
nate. The fluid then enters the bladder and posterior 



602 ASTRINGENTS IN GONORRHEA 

urethra. It is sometimes necessary to anesthetize the 
urethra by the injection of ten c.c. of a weak local 
anesthetic, such as 1 per cent, stovain. 

The irrigations should be employed at least once 
daily and should be continued as long as a discharge 
is present. This may be as much as two weeks ; they 
should then be gradually discontinued, giving irriga- 
tion every other day, twice weekly, and finally once 
each week. 

Potassium permanganate is used in strength of 
1:8,000. Albargin is used in strength of 1:1,000. 
Protargol is used in from 1 : 1,000 to 1 :2,000 strength, 
and argyrol from 1 :500 to 1 :250. 

ASTRINGENTS 

As soon as the gonococci have disappeared and 
been absent for several days a continued catarrh of 
the anterior urethra is best treated by astringents, 
and there is probably none better than the generally 
used zinc sulphate. At first injections may be given 
twice daily, rarely three times daily, and then gradu- 
ally reduce the frequency. While zinc sulphate is 
often combined with several other ingredients for 
injection, it probably acts as well in simple solution, 
as follows: 

Gm. or C.c. 

B Zinci sulphatis 150 or gr. viii 

Aquae 100| AS iv 

M. Sig. : Use externally as directed. 

Pusey has suggested also the following: 

Gm. or C.c. 



1$ Zinc sulphate 

Resorcin 1 

Water 100 

B Zinc sulphate 

Phenol 

Water 100 

Ifc Zinc sulphate 

Lead acetate 

Water 100 



60 gr. xii 

25 or gr. xxiv 
00 3iv 

60 gr. xii 

20 or gr. iv 
00 Siv 

40 gr. viii 

80 or gr. xv 
00 Siv 



This subacute stage of gonorrhea should cease in 
about two weeks, and if it persists longer it seems 
probable that there is some complication of a previous 



MERCUROCHROME-220 603 

inflammation or a localization that should be definitely 
treated. If at any time during this subacute stage the 
secretion shows gonococci, the silver albuminoid injec- 
tion may be used. During this stage the same restricted 
diet should be continued, but more exercise may be 
allowed. 

If posterior or anterior urethritis persists with gono- 
cocci absent after the period of subacute inflammation 
has passed, the use of silver nitrate solutions has been- 
advised. The whole length of the anterior urethra 
may be treated through an endoscope by means of a 
cotton swab medicated with 0.5 or 1 per cent, nitrate 
of silver solution or there may be instilled by means 
of a deep urethral syringe a syringeful of a 1 : 5,000 
to 1 : 250 solution of nitrate of silver, or a few drops 
of a 0.25 to 0.5 per cent, solution. Such treatment 
should not be repeated oftener than once in five days. 
The passing of all instruments through the urethra, 
even in this late stage of gonorrhea, should be done 
with the greatest care, and thin, bland oils are the 
best lubricants. 

MERCUROCHROME-220 

Impressed with the possibilities of using dyes as a 
basis for the development of therapeutic compounds, 
Young, White and Schwartz (Jour. A. M. A. 73: 1483 
1919) concentrated efforts on the production of new 
drugs possessing the penetrating qualities of dyes while 
at the same time being germicidal and relatively non- 
toxic and nonirritating. Mercurochrome-220 they 
found could be shown to have germicidal value. The 
speed with which some old infections of the bladder 
and kidney pelvis disappeared after its use was strik- 
ing, and the absence of irritating and toxic qualities, 
together with the ability of the patient to retain a 1 
per cent, solution for hours without discomfort, suffi- 
ciently proved to establish the possibilities of the drug 
in these conditions. 

Its value in colon and staphylococcus infections led 
them to apply mercurochrome-220 to gonorrhea and 
chancroidal ulcerations. Solutions of this drug in 
strength from 0.1 to 5 per cent, have been used in the 



604 COMPLICATIONS OF GONORRHEA 

human genito-urinary tract as a local antiseptic. In 
the kidney pelvis a 1 per cent, solution was used. This 
was slowly injected through the ureteral catheter, the 
catheter was plugged, and the solution was retained for 
five minutes. There was no sign of irritation or reac- 
tion following its use. This procedure was carried out 
three times in one week in some instances. In the 
urethra a 5 per cent, solution caused only temporary 
•burning when retained five minutes, and a number of 
cases of acute urethritis were treated by the use of 1 
per cent, solution injected four times a day, the solu- 
tion being retained five minutes at each injection. 
There was no irritation beyond occasional temporary 
smarting. No cases of retention were seen, and no 
stricture formation resulted from its use in a series of 
cases. 

In treating acute anterior gonorrhea a 2.5 per cent, 
solution of mercurochrome instead of 1 per cent, has 
been later recommended. This may be used every three 
hours, and should be preceded by a cleansing irrigation 
of sterile Water. It causes a little more burning than 
the 1 per cent, solution, which, however, is temporary. 
On incomplete data, it seem that the time necessary to 
render the urethra organism free is definitely shortened 
by the use of this stronger solution. No unfavorable 
complications have been observed. Cases were also 
treated by the use of 5 per cent, mercurochrome in 
lanolin, and petrolatum equal parts. 

COMPLICATIONS 

If the morning drop persists follicular urethritis is 
probably present, irrigations are advisable, as if solu- 
tions pass from the anterior urethra back into the blad- 
der they cleanse the mouths of the follicles which are 
directed forward, and the retained secretions are thus 
removed. For this purpose a solution of 1 : 30,000 of 
bichlorid of mercury or a saturated solution of boric 
acid, or a 1 : 2,000 potassium permanganate solution 
may be used. The solution selected should be given by 
the ordinary irrigation apparatus, viz., a short glass 
urethral tube and the pressure necessary to cause the 
solutions to flow gently into the bladder. 



PROSTATITIS 605 

If there is great disturbance from the posterior 
urethritis, the patient should be put to bed. The 
anterior urethra may be washed with boric acid solu- 
tion and then the mucous membrane anesthetized with 
a 2 per cent, solution of eucain or 1 per cent, stovain, 
and a soft rubber catheter, 14 to 16 French, passed 
into the deep urethra. Then instill into the deep 
urethra 2 or 3 fluidrams (from 10 to 15 c.c.) of a 
silver albuminoid solution, or a solution of nitrate of 
silver in strength of 1 : 5,000 to 1 : 1,000. Such instilla- 
tion may greatly relieve the patient of his distressing 
symptoms. This treatment may be repeated in a day 
or two, if it proves to be necessary. 

It should not be forgotten that these apparently 
severe symptoms of a posterior urethritis may really 
be a prostatitis, or even the beginning of a prostatic 
abscess. 

A posterior urethritis pure and simple in the acute 
stage of gonorrheal arthritis will rarely need irrigation 
treatment. As a general rule, it will be found that hot 
baths, absolute rest, a milk diet and the administration 
of alkalies will within twenty-four hours stop the 
intensity of the symptoms. 

VACCINE AND SERUM THERAPY 

Vaccines, serums, sensitized vaccines and autogen- 
ous serums have been used in gonorrhea and its com- 
plications* with startling reports of success or of 
complete failure. These methods seem particularly 
adapted to the treatment of the complications. 






PROSTATITIS AND SEMINAL VESICULITIS 

The most' frequent, and the only frequent cause of 
inflammation of the prostate and of the seminal vesi- 
cles is gonorrhea. Without regard to the importance 
of acute inflammation of these parts the chronic and 
persistent harboring of the gonococcus by these organs, 
making the carrier of these germs a menace to himself 
and others, makes the subject of vast importance. It 
is hardly necessary to state that most gynecologic 
inflammations are due to the gonococcus, and most 
frequently the infection is received innocently and is 



606 PROSTATITIS 

due to a latent gonorrhea, or a chronic prostatitis or 
vesiculitis due to an uncured gonorrhea in the male. 
Chronic gonorrheal infection of the prostate and semi- 
nal vesicles is of comparatively frequent occurrence. 
The symptomatic evidences may be slight. There 
often is an increased frequency of urination; there 
may be a feeling of fulness or uncomfortableness in 
the perineal region ; there may be a slight sticky or 
mucopurulent exudate and the urethral drop, and the 
urine may be cloudy. On the other hand, the urine is 
not always cloudy with this subacute or chronic pros- 
tatitis. 

While it is probably rare to find gonococci in pros- 
tatic exudate a year after the original infection, it does 
occur, and before a year the gonococci may be fre- 
quently found when there are no apparent evidences 
of the previous gonorrheal infection. When following 
massage of the prostate and stripping of the seminal 
vesicles the examination of the slide from the drops 
of secretion exuded from the urethra show gonococci, 
of course the diagnosis is positive. If such an exam- 
ination shows no gonococci in a suspected individual, 
it has been suggested that from 1 to 2 c.c. (5 to 10 
minims) of a 1 per cent, solution of nitrate of silver 
be injected into the posterior urethra with the Ultzman 
syringe. The stimulation from this injection will 
cause, the next day, an increased discharge, which 
should cause gonococci to be found on microscopical 
examination, if they are still present. 

Besides the local symptoms described of chronic 
prostatitis, patients who are suffering from this con- 
dition often have symptoms of neurasthenia and hypo- 
chondriasis. Men otherwise well, with no apparent 
_ cause for symptoms of nerve tire, should be carefully 
questioned as to previous gonorrheal infection, and 
the prostate and any secretion that can be expressed 
from it should be carefully examined, even if the local 
symptoms are negative. 

Acute gonorrheal inflammation of the posterior 
urethra is, of course, readily diagnosed by the cloudi- 
ness of the urine. A later involvement of the pros- 
tate or seminal vesicles is diagnosed by the finger 
passed well up the rectum and noting the enlargement 



TREATMENT OF PROSTATITIS 607 

and tenderness of the prostate, and, if the seminal vesi- 
cles are involved, by noting their fulness and tender- 
ness. Normal seminal vesicles are hardly palpable. 

Acute inflammation of the prostate and vesicles 
should be treated with rest, a diet of milk and simple 
cereals, plenty of water should be taken, and hot sitz 
biths once or twice a day. The urine should at first 
be rendered alkaline with potassium citrate during the 
acute irritation, and later hexamethylenamin or salol 
(phenyl salicylate) should be administered. There 
should generally be no urethral injections and no 
manipulation of the prostate, and certainly no passing 
of instruments into the urethra. If the prostatitis 
becomes localized and causes an abscess, of course 
the treatment is surgical interference. 

In subacute prostatitis the prostate should be gently 
massaged, and some of the exuded fluid which is 
received on a glass slide should be examined under the 
microscope for pus and gonococci. Generally, there 
will also be found living spermatozoa and often dead 
spermatozoa, with prostate epithelial cells, and perhaps 
crystals of spermin. The tenderness of the prostate 
determines the frequency and the amount of massage 
that it should receive ; perhaps every second day for a 
short time, and then twice a week. At each massage 
the seminal vesicles should be thoroughly stripped. 
During this subacute inflammation all violent exercise 
must be prohibited; alcohol should certainly not be 
allowed, and the patient is usually better without 
tobacco than with it. Tea and coffee, if allowed at all, 
should be in small amount. Constipation should be 
guarded against, particularly in prostatitis. It is 
always best to wear a suspensory bandage during 
acute gonorrhea, and during acute and subacute inflam- 
mation of the prostate. 

The prognosis is good if the patient will give himself 
the proper rest in the acute condition, if he will take 
care of himself in the subacute condition, and will 
persist long enough in his treatment of the chronic 
condition. 

If gonococci are present in this secretion in subacute 
or chronic inflammation, vesical injections of weak 
silver solutions, such as from 1 : 500 to 1 : 1,000 of 
one of the silver albuminate preparations, should be 



608 TREATMENT OF PROSTATITIS 

given daily or every other day, and at least every other 
day or generally every day the prostate should be mas- 
saged while the solution is in the bladder. The patient 
then urinates and thus washes out the bladder. These 
bladder washings should gradually be less frequently 
repeated, and as soon as the gonococci are found 
absent from the prostatic secretion, the bladder injec- 
tions are given only infrequently. A microscopic test 
should be made once a week for three or four times, 
and then again in a month. The gonococci remaining 
absent, the patient may be considered cured of the 
infection. The old assertion that when the gonococci 
had infected the prostate and vesicles the patient could 
never be cured, but harbored them for the rest of his 
life, is probably not now true if the affected individual 
will allow himself to be properly treated before the 
germs have found a more permanent harbor deep 
within the glandular tissue. 

In chronic prostatitis without gonococci, or after 
the gonococci have disappeared, besides massage of the 
prostate once or twice a week, local applications can 
be made by high injection of from 1 or 2 c.c. (5 or 
10 minims) of various silver solutions, the strength 
of which should vary from 1 to 3 per cent. Instilla- 
tions should not be used more frequently than once in 
five days. Not infrequently the double closed catheter, 
which allows the circulation of cold water, is one of the 
best tonic treatments of the posterior urethra and 
prostate. Such treatment is indicated only in the 
chronic form of the inflammation when the prostate 
has not returned to its normal size, normal tone and 
normal feel. 

In chronic gonorrheal infections particularly the 
vaccine and serum preparations seem to offer most 
hope of success. They may certainly be given a trial. 

Smith, Lusk and many foreign observers have 
reported very successful results in chronic gonorrheal 
complications from injections of foreign proteins, pro- 
ducing a marked reaction with high temperature fol- 
lowed by a disappearance of the gonococci from the 
tissues and exudate obtained on stripping. The sen- 
sitivity of the gonococcus to high temperatures is a 
good theoretical basis for the use of such treatment, 



CHANCROID 609 

and in very obstinate cases where there are no compli- 
cations this treatment might be tried as a final resort. 
The method is described in the discussions of chronic 
arthritis and of psoriasis. 

CHANCROID 

Chancroid is a condition occurring only among those 
who are careless and dirty, as evidenced by the fact 
that it is easily prevented by prophylactic treatment 
consisting simply of thorough washing with soap and 
water. The great danger of chancroid is that it is 
sometimes mistaken for syphilis or that syphilis is 
overlooked and the condition diagnosed as chancroid. 
Regardless of the appearance, duration or previous 
treatment of a venereal sore it should always be exam- 
ined for the presence of the spirocheta pallida. 

Wassermann tests should also be made on these 
patients in every case. 

The patient should be put to bed, kept clean and 
given a nourishing diet. In many cases abortive treat- 
ment is advisable. The chancroid may be thoroughly 
eradicated with the actual cautery, the patient being 
given a general anesthesia preferably of nitrous oxid 
oxygen. Chemical cauterization is also used. Robbins 
and Seabury have suggested local anesthesia and then 
the application of a 25 per cent, solution of copper 
sulphate in distilled water accompained by the short 
high frequency spark from a rather fine pointed 
vacuum electrode for from one to three minutes. The 
current is not turned off until every crack and crevice 
has been thoroughly treated and the surface of the 
sore is changed to a dark greenish gray. .It is then 
wiped dry and some antiseptic powder is applied. 

This treatment is not applied where the healing 
process would yield distressing deformity, where there 
is intense inflammatory reaction or much edema, where 
there is inguinal adenitis or bubo, or when the condi- 
tion is healing spontaneously. In such cases reliance 
is placed on ordinary antiseptic treatment to promote 
healing. Such solutions as warm saturated boric acid, 
mercuric chlorid, 1 : 10,000, or potassium permanga- 



610 HYPERTROPHY OF THE PROSTATE 

nate, 1 : 3,000, may be used. In very acute cases, Pusey 
suggests the application of liquor alumini subacetitis, 
one part to fifteen parts of water. If wet dressings are 
impracticable, antiseptic powders and protection may 
be used. 

If the chancroid is complicated by phimosis subpre- 
putial irrigations with mild antiseptic solutions should 
be used and if this does not check the condition the 
prepuce may be freely incised down the dorsum. The 
sores being exposed are then easily treated and after 
the inflammation has wholly subsided circumcision may 
be done. It should not be done in the presence of 
active inflammation. 

CHRONIC HYPERTROPHY OF THE PROSTATE 

This condition should be distinguished from enlarge- 
ment of the prostate due to a subacute prostatitis, 
which is an inflammation that affects the ducts and is 
generally due to an infection that has come from the 
urethra. Although this enlargement of the prostate 
may persist for some time, proper local applications 
and massage will generally effect a complete cure. 

True chronic hypertrophy of the prostate develops 
insidiously and is of frequent occurrence as it is 
present, in various grades, in about 65 per cent, of all 
men after the age of 50. The treatment of this condi- 
tion is well discussed under three heads : prophylactic, 
palliative, and operative. 

PROPHYLAXIS 

As the etiology of chronic hypertrophy is not clearly 
understood, it is difficult to lay down a definite rule 
for prophylaxis. While it is probable that this is a 
normal accompaniment of old age, the reason that it 
occurs so frequently at an earlier age, from 50 to 60, 
may be because of excessive or abnormal sexual activ- 
ity. Investigations seem to show that benign hyper- 
trophy occurs very much more frequently in the mar- 
ried man than in the single man. 

There seems to be no question that frequent, and 
especially abnormal sexual excitement does congest the 
prostate, and repeated prostatic congestions lead to a 



SYMPTOMS OF PROSTATIC HYPERTROPHY 611 

slow hypertrophy. It is also probable that a bad heart 
which allows venous congestions, especially when the 
veins of the pelvis (and the hemorrhoidal veins espe- 
cially) are dilated, would become an impetus to passive 
congestion and later to hypertrophy of the prostate. 
Persistent constipation would be another added cause 
of this passive congestion. Bladder irritation and irri- 
tability, if frequently repeated and never completely 
cured, could be a cause; while varicocele could be 
another cause for prostatic congestion. In other 
words, anything that tends to repeated pelvic acute 
congestion or chronic pelvic passive congestion may 
well be an exciting cause to the enlargement of the 
prostate, which organ is always apparently ready to 
enlarge after the age of 50. Consequently, any treat- 
ment that removes or prevents these congestions would 
be prophylactic treatment against hypertrophy of this 
gland. 

EARLY SYMPTOMS 

The early symptoms of an enlarging prostate are 
increasing frequency of urination, especially at night; 
slight delay in starting urination, especially early in the 
morning or when the bladder is full ; and a slight dimi- 
nution in the expulsive force of the stream. These 
symptoms have usually been present many weeks, and 
even months, before the physician is consulted. By 
this time the hypertrophy has advanced to a consid- 
erable degree, and enlargement of the prostate, as 
shown by examination, is generally positive. The 
question immediately arises as to whether palliative 
treatment should be advised or an immediate operation 
performed. 

It would seem unwise, even with the very low mor- 
tality when the operation is done at this period, from 
the fact that there is a mortality, to urge immediate 
operation. Neither the condition itself nor the opera- 
tion is really the cause of the mortality, but it is due to 
the concomitant or coincident insufficiency of the kid- 
neys, possibly to an arteriosclerosis. It should be 
remembered that when a man is suffering from chronic 
hypertrophy of the prostate he also has probably used 
his circulatory system to excess, the arterial tension 



612 SYMPTOMS OF PROSTATIC HYPERTROPHY 

is generally high, the heart may be in perfect condition 
but undoubtedly the left ventricle has become hyper- 
trophied to combat normally increased tension of 
the man's life and the increased tension of the arterial 
system due to advancing years. Also, although the 
urine apparently may be perfectly normal, the kidneys 
are often imperfect at this age, as would be evidenced 
by repeated examinations of the twenty-four hours' 
urine on different diets and under different irritations 
or exertions. In other words, kidneys that are perfect 
during the ordinary daily life, when the patient is sub- 
jected to anesthesia or to the slight shock or distur- 
bance of an operation, become insufficient, and uremic 
symptoms readily develop. Therefore, the treatment 
of the above condition should at first be palliative. 

The great source of danger is residual urine, i. e., 
the urine which remains in the bladder after the patient 
has urinated and which he cannot evacuate by volun- 
tary effort. That there is a residual urine can be deter- 
mined only by the passage of a catheter. A soft rubber 
catheter, properly sterilized, can generally be passed 
without difficulty, this after the patient has urinated, 
and after the parts are thoroughly cleansed and ren- 
dered aseptic. A study of the urine that the patient 
passed (and best a study of it in the two-glass test), 
and a study of the urine which may be drawn by cathe- 
terization, i. e., the residual urine, will not only deter- 
mine the character of the urine, but also the condition 
in the bladder. An acid urine, clear, without pus, 
without much mucus, without blood caused by the cath- 
eter rubbing over the prostatic urethra, shows that 
temporizing and palliative treatment should be the 
treatment elected. The evacuation of clear urine by 
the patient does not positively preclude the possibility 
of even a large amount of residual urine, as absolutely 
clear urine may be passed on repeated days and yet 
catheterization remove a large quantity of turbid 
residual urine. If there is no residual urine, good, 
sensible tonic treatment, a proper amount of rest, a 
properly regulated diet, good management of the bow- 
els, prevention of chilling, and the happy medium of 
never attempting to hold the urine too long or on the 
other hand answering every frequent flitting desire to 
urinate, may hold the patient in the same condition for 



•TREATMENT OF PROSTATIC HYPERTROPHY 613 

months or even years. It is undesirable to allow the 
patient to urinate too frequently, because it prevents 
the bladder from becoming normally distended, and 
the viscus becomes smaller and smaller until life 
becomes a misery. 

If there is much mucus from the bladder, or if there 
is prostatic irritation sufficient to give local aching or a 
pain in the penis, the first treatment should be to draw 
the residual urine, then gently wash the bladder with 
a warm 2 or 3 per cent, boric acid solution. When 
the bladder washings are clean, the bladder should 
once more be filled with the warm solution and then 
the catheter removed and the patient allowed to pass 
the liquid. Care should be taken not to over-distend 
the bladder with these solutions. This washing may 
be done every day for a few times and then infre- 
quently, or absolutely stopped if the symptoms subside. 

If there is but little mucus in the urine, and vesical 
irritability, especially at the neck of the bladder or per- 
haps slight referred pain at the penis, the instillation 
into the bladder of 1 c.c. (15 minims) of a 1 per cent, 
solution of nitrate of silver, once in five days for a 
few times, or injection into the bladder of 60 c.c. 
(2 ounces) of a 1 : 5,000 solution of nitrate of silver 
and then withdrawing the catheter and allowing the 
patient to pass the solution, will frequently effect a 
temporary cure, and may give the patient relief for 
months. 

If pus is present in the urine and the condition "is 
acute cystitis, the usual treatment of this condition 
must be given, viz., daily bladder washings with warm 
boric acid solution. If a chronic cystitis has already 
developed, the bladder washing must be with some of 
the various silver solutions, either an organic silver 
solution or a very weak nitrate of silver solution. The 
silver solution must not be used too frequently. One 
would hardly advise an operation during an acute 
cystitis, and would not urge it in chronic cystitis until 
the bladder was as surgically clean as possible; in 
other words, after prolonged, proper treatment, with 
the patient at rest. It is unnecessary to state that an 
operation, when chronic cystitis is present, i. e., when 
an infection is present, is of serious prognosis. It is 
impossible to tell how much the ureters may have 



614 TREATMENT OF PROSTATIC HYPERTROPHY 

become infected or whether the kidneys have been 
injured from the infection in the bladder, to say noth- 
ing of their secretory ability. 

Whenever there is cystic irritability or genito- 
urinary inflammation the diet should be just as care- 
fully regulated as is so well understood in specific 
urethritis, viz., in acute cystitis or in acute irritability 
of the bladder a milk and cereal diet should be given 
with rest and hot general baths. In chronic inflamma- 
tion of the bladder or of the prostatic region daily hot 
sitz baths are of great benefit, and the diet should con- 
sist of simple meats,- ordinary vegetables, cereals, and 
fruit. Highly spiced foods, coffee and tea, and gen- 
erally tobacco, should be forbidden; alcohol should be 
interdicted, and no drugs should be given that could 
irritate the genito-urinary tract. The bowels should be 
carefully regulated. Constipation does harm in all 
pelvic inflammations. 

Acute irritability of the bladder may be partially 
relieved by the judicious use of drugs that render the 
urine alkaline, but when there is an enlarged prostate 
and any tendency whatever to residual urine, the urine 
should not be rendered long alkaline. The simplest 
prescription for this purpose is : 

Gm. or C.c. 

B Potassii citratis 401 or 5 ii 

Aquae gaultheriae . . . 200| fl§ viii 

M. Sig. : Two teaspoonfuls, in water, three times a day, 
after meals. 

It is often inadvisable to have the patient drink a 
great deal of water, as it will overfill the bloodvessels 
(the age of the patient must not be forgotten), raise 
the arterial tension, increase the frequency of urina- 
tion, and may precipitate the occurrence of residual 
urine. 

If there is chronic cystitis, no drug (provided the 
urine is rendered acid) is probably more valuable than 
hexamethylenamin, which may be given as follows: 

Gm. or C.c. 

R Hexamethylenaminae 10| or 3 iiss 

Fac chartulas, 20. 

Sig. : A powder in half a glass of water, three times a day, 
between meals. 



USE OF CATHETERIZATION 615 

CATHETERIZATION 

If there is residual urine and this (which may vary- 
in amount from day to day) persists it is only a 
question of time when the patient will have a sud- 
den stoppage and be unable to empty the bladder 
and must send for a surgeon for immediate catheteri- 
zation on account of distention of the bladder with 
resulting paralysis. This having once occurred, some 
surgeons advise the use of a catheter continuously. It 
is possible in such an instance that if a proper attendant 
with the most careful cleanliness uses the catheter at 
least three times in twenty-four hours, and perhaps 
better four times, in a few days the bladder may return 
to its proper tone and may be as good or better than 
it has been before for a number of months, i. e., may 
not contain so much residual urine. This should be 
tried. If, on the other hand, the bladder does retain 
residual urine, and the urine tends to be alkaline and 
turbid, the man must be given a catheter to use him- 
self, either once in twenty-four hours to remove all 
residual urine, or three times in twenty-four hours if 
he cannot at any time well evacuate his bladder. This 
kind of treatment is sometimes necessary on account 
of the inadvisability of operating, but is generally inex- 
cusable, as it is only a question of time when such a 
bladder will become seriously infected and chronic 
cystitis, incurable, will be the result, and cause the 
death of the patient. Therefore, unless there is some 
positive reason why a man can not be operated on, 
operation should be advised, and advised before infec- 
tion has occurred. 

Some patients develop a chill after the passage of 
even a soft rubber catheter, or even have what has 
been called urethral fever, with considerable rise of 
temperature for some hours. This is not of frequent 
occurrence, and may never be seen by an individual 
practitioner. Other surgeons have seen it so frequently 
that they recommend the administration of some 
drug to prevent this hyperirritability of the urethra, 
such as bromids, and even quinin has been recom- 
mended. If such a reaction occurs, the patient should 
be kept in bed for twenty-four or thirty-six hours and 
treated symptomatically. No harm seems to come 



616 OPERATION FOR HYPERTROPHY 

from the disturbance. This fever is probably an 
anaphylaxis due to erosion of the urethra and absorp- 
tion of bacterial or protein poison. 

Simple palliative treatment of the condition being 
unsatisfactory, reflex pain in the penis or irritability 
of the bladder, persisting, cystoscopy should be care- 
fully done, and the possibility of a stone in the bladder 
should be considered. It must, however, be urged that 
a mild subacute condition is often precipitated into an 
acute one by such instrumentation. However, it is a 
means to an end, i. e., positive diagnosis of the condi- 
tion, and must often be done, but not done without 
due and careful consideration. To save repeated 
instrumentation, at the same time the bladder is cysto- 
scoped, it is well to pass a catheter into each ureter to 
examine the urine from each kidney separately. The 
results of this examination will aid in the decision as 
to whether or not an operation should be performed. 
The value of roentgen ray pictures should also not 
be forgotten. Various functional tests, phenolsul- 
phonephthalein, phloridzin, urea, etc., show whether 
the kidneys are at fault or whether the trouble is 
chiefly prostatic. 

OPERATION 

It is the object of the careful physician and surgeon 
to aim to determine when palliative treatment is use- 
less or in any given patient is becoming useless, to 
advise operation if the kidneys and circulation are in 
good condition before the patient becomes miserable, 
before the bladder has become infected, before the 
bladder has become seriously thickened, and before it 
has become paralyzed from over-distention or has 
become badly contracted from protracted and frequent 
efforts to expel urine over the obstacle of the enlarged 
prostate. As before stated, infection of the bladder 
may creep up toward the kidneys, and with infection 
of the bladder, and even without it, continued pain and 
irritation in this region may cause a general debility, 
loss of appetite, emaciation and feebleness. Of course, 
any of these conditions being present when the patient 
first comes to the physician would demand, first, rest, 
careful preparation of the bladder and the pushing of 



OPERATION FOR HYPERTROPHY 617 

nutrition, and second, operation ; but the patient having 
been under a physician's care the operation should be 
advised and done before he reaches this sad condition. 

Which particular operation is best for a given indi- 
vidual, or the technic of the operation are questions of 
surgery; it is enough for the physician to decide that 
an operation is necessary. The results of prostatec- 
tomy are surprisingly good when one takes into 
account the advanced age of many who submit to the 
operation, the frequent coincident cystitis, the history 
of prolonged pain and often debility of the patients, 
and the impairment of circulatory and excretory 
organs concomitant to their age. Many patients over 
80 years of age are operated on with good results and 
their lives greatly prolonged by the operation, and the 
mortality has been placed even below 4 per cent. 

The differential diagnosis between tumors of the 
prostate and simple hypertrophy of the prostate can not 
well be described. The greater amount of pain in most 
tumors of this age (the most frequent being cancer), 
with the greater rapidity of growth, with the nodular 
feel and enlargement in all directions as well as into 
the bladder, generally quickly shows that the enlarge- 
ment is malignant and not benign. 



_ 



OBSTETRICS AND GYNECOLOGY 



TOXEMIAS OF PREGNANCY 

The disturbances which occur during pregnancy and 
some of the severe conditions at parturition are due to 
varying causes. The treatment that is efficient and 
satisfactory in one instance may not be efficient in 
another. The view has been advanced that the condi- 
tion is essentially anaphylactic in character. Intestinal 
indigestion, disturbances of the parathyroids and thy- 
roid; disturbances in the fetal organism, in the pla- 
centa, in the kidneys and in the liver may be a cause. 

Since it is positively demonstrable that serious tox- 
emias may be caused by prolonged constipation, it is 
certainly logical to presume that constipation even in 
a mild form is provocative of the absorption of toxins 
that should have been eliminated by the intestines. 
These toxins seriously impair the perfect activity of 
the liver, to which they first go through the portal 
circulation. If the liver is so continuously irritated, 
it can not well do its normal work. Toxins or irri- 
tants to metabolism soon get through this filter into 
the systemic blood and cause nervous, circulatory and 
kidney irritations. Such irritations at first, and per- 
haps continuously, may be inconsequential, but they 
may be the forerunners or the instigators of serious 
conditions in the latter part of the pregnancy. A 
primary axiom in pregnancy, then, should be that 
constipation must not be allowed, and such means 
must be inaugurated and persisted in as will prevent 
constipation, intestinal stasis, intestinal fermentation, 
putrefaction and the absorption of toxins. If any 
one of the digestive organs is not properly functioning 
it should be assisted, if possible. The diet should be 
so arranged as not to aggravate this disabled organ, 
and to relieve it of as much work as possible. 

HYPOTHYROIDISM 

It has been demonstrated, apparently, both physio- 
logically and clinically, that the thyroid gland normally 
hypersecretes during pregnancy. If the thyroid does 
not secrete properly, various toxemias occur. A mal- 



TOXEMIAS OF PREGNANCY 619 

secreting thyroid may be related to pernicious vomit- 
ing during pregnancy, can certainly interfere with the 
nutrition of the fetus, and can interfere with the 
health of the mother. 

If by a careful study of the pregnant patient it is 
decided that the thyroid gland is not properly secret- 
ing, thyroid substance should be administered. The 
dose during pregnancy should be small. Just preceding 
parturition, if it is feared that eclampsia may occur, 
and especially if the kidneys are insufficient, thyroid 
may be given in larger doses. If a patient gives birth 
to a child showing imperfect development or symptoms 
of under-thyroid secretion, although it might not be 
a cretin, thyroid may be administered to the mother 
throughout her subsequent pregnancies, unless symp- 
toms forbid its use. A daily dose for a pregnant 
patient, short on thyroid secretion, should not be more 
than 0.20 gm. (3 grains) once a day, and generally 
half that dose is enough, while a patient who shows 
serious toxemia or critical symptoms of metabolic 
poisoning should receive 0.30 gm. (5 grains) three or 
four times a day for a short period. A patient needing 
thyroid just before or during parturition may be given 
0.60 gm. (10 grains) once or twice, while a patient 
with eclampsia may be given 1.30 gm. (20 grains) at 
one dose. 

OTHER CAUSES OF TOXEMIA 

Malnutritions of the fetus and degenerations of the 
placenta may cause the formation and absorption of 
toxins that poison the mother. The cause being dis- 
covered and improvement not soon taking place would 
seem to call for cleaning out the uterus — this, of course, 
after a consultation. 

An uncomplicated true nephritic toxemia should 
certainly be discovered. A uremic condition from 
nephritis of pregnancy must almost always be a pro- 
gressive condition. Consequently a progressive chronic 
nephritis can only be overlooked by utterly neglecting 
to make proper examination of the urine. If a chronic 
nephritis, by evidences in the urine, shows a progres- 
sive inflammation, a final toxemia, due to allowing 
a pregnancy to continue too long before interference, 



620 VOMITING OF PREGNANCY 

should be prevented. Consequently the most serious 
toxemias and eclampsias are those that do not present 
kidney symptoms or signs until the last moment, and 
these toxemias are due primarily to disturbances of 
other organs than the kidneys, generally perhaps some 
endocrine disturbance. 

If the kidneys were previously healthy, i. e., if an 
insidious chronic interstitial nephritis was not pres- 
ent, a nephritis due to pregnancy should be quickly 
recognized by the albumin in the urine. Therefore, an 
examination for albumin and casts is usually sufficient 
to show whether the kidneys are in primary trouble 
or not. 

TREATMENT 

Every effort should be made to relieve the kidneys 
by getting the skin and bowels to act and by the 
administration of a carefully modified diet. If 
there be headache or edema the patient, in addition, 
should be kept in bed and should have hot baths, 
free purgation and a milk diet. If the condition 
becomes more severe, warm saline lavage of the 
stomach and intestines is useful. In the nephritic 
cases, if in spite of this method of management the 
patients get worse, labor should be induced. One of 
the most important points emphasized is that a preg- 
nant woman's urine must be analyzed once a month 
during the first six months of gestation, and at least 
once a fortnight after that period. 

VOMITING OF PREGNANCY 

The cause of severe vomiting of pregnancy has not 
been determined. The condition most frequently 
appears between the third and fifth week of preg- 
nancy. Among many causes which have been sug- 
gested are reflex influences such as pressure on nerves 
connected with the uterus, stomach and other abdom- 
inal viscera (and of these the most important are those 
due to displacement of the uterus and its adnexa) 
neurotic, toxemic and some endocrine gland distur- 
bance. 

First, then, a complete history of the patient should 
be taken, an opinion formed as to her normal mental 
or nervous temperament, and a thorough and complete 



UTERINE DISPLACEMENT IN PREGNANCY 621 

physical examination made. If the condition is due to 
hysteria, the patient should generally be isolated and 
moved if possible to a situation where she will have 
an entire change of surroundings and attendants; the 
treatment then becomes mostly hygienic and sugges- 
tive. 

Jung (Deut. Med. Wchnschr., 1916, 42, p. 61) 
emphasizes the importance of discriminating between 
the ordinary harmless vomiting of pregnancy and the 
serious type. The loss in weight is the criterion, but 
this must be determined with precision, weighing the 
woman every third day under like conditions and on 
a good scale. The best time for this is following 
defecation after breakfast, with the clothing always the 
same. The amounts eaten must be recorded in writing 
for each meal, and the vomit must be saved to show 
the physician. To prevent ordinary vomiting from 
developing into the severe type, he orders the break- 
fast to be taken in bed, with an hour's repose after- 
ward. Food should be taken often and never much 
at a time, preferring fluid food at first but resuming 
the ordinary food as soon as possible, omitting all 
dishes which the woman does not like in health, 
impressing on the patient that if the directions are 
closely followed there will be no vomiting. The stom- 
ach is not responsible in any way for the vomiting, 
and hence does not require special treatment. In the 
severe type we must stop all intake of food and fluid. 
This is difficult and sometimes impossible in the home. 
If the woman is really losing weight, she should be 
placed where the starvation treatment can be given a 
thorough trial before resorting to the evacuation of 
the uterus. The transference to the hospital in itself 
has a pronounced effect on the nervous predisposition. 

UTERINE DISPLACEMENT 

If examination reveals a misplaced uterus (and 
probably a retroversion is that most frequently found), 
replacement should be made immediately and a prop- 
erly adjusted pessary placed to maintain the correction 
until such time as the enlarging uterus will retain its 
proper position unaided. Occasionally adhesions may 
be found which prevent the manual correction of the 



622 NUTRITION IN PREGNANCY 

fault. The condition then becomes more formidable, 
and recourse must be had to surgery. The same 
holds good in incarceration, and in this condition not 
infrequently corrective measures result in abortion. 
Erosions of the cervix, cicatrices, and polypi may be 
causes of the nausea and vomiting, and these if found 
should receive proper attention. However, surgical 
procedures, unless of a most trivial nature, should be 
reserved as a last measure, since they are liable to 
induce abortion, as are also such procedures as may 
require either a tampon of any considerable size, or 
packing of the vagina. If the vomiting still persists 
after all corrective measures possible have been made, 
it may probably be assumed to be due to intoxication. 

SUPPORTING NUTRITION 

The two great difficulties are the maintenance of 
the patient's nutrition and the combating of the pros- 
tration caused by the vomiting. Under whichever 
heading we choose to meet the case, hygienic mea- 
sures stand first and nothing should be omitted which 
tends to their furtherance. The diet should be of the 
simplest, and milk should form its bulk. One after 
another of its simple dishes must be tried, to be dis- 
carded if they are not retained. When the patient is 
first seen, if the stomach is washed out and nothing 
allowed but water for twenty-four hours, the bowels 
being thoroughly cleaned out meanwhile, milk will 
generally be retained. Just before giving the milk a 
small dose of morphin, 0.005 gm. (1/12 grain) sub- 
cutaneously, may cause it to be retained. If it is 
retained, the drug may be given previous to fur- 
ther administration of food, lessening the dose each 
time, and, not infrequently, when a placebo is ulti- 
mately substituted for them, the food will be retained 
as well. Sooner or later, unless conquered, even idi- 
opathic cases are found to have their etiology in intoxi- 
cation and elimination becomes the main point of all 
treatment. 

If the vomiting persists, nothing should be allowed 
by the mouth for a day, and four nutrient enemas 
should be given instead. These are disagreeable to 
the patient and sometimes the vomiting stops abruptly 



HYGIENE IN PREGNANCY 623 

when she is told that mouth feeding will be resumed 
when she stops vomiting. Formulas for such nutrient 
enemas will be found under the article on rectal 
feeding. 

The urine of course should be examined with great 
frequency and close watch should be kept on the 
elimination of solids, but an undue anxiety because 
of their diminution should not be felt when the intake 
of food or the food retained is small. A due regard 
to this should be kept in mind. 

HYGIENE 

The bowels should be moved freely once a day, with 
such simple laxatives as are efficient in her case. 

Daily warm baths, with massage, plenty of fresh air, 
the patient kept in bed, the avoidance of the odor of 
cooking food, and the avoidance of all measures that 
tend toward excitement are to advantage. Counter 
irritation by mustard plaster or turpentine stupes 
placed over the stomach is generally a help and some- 
times efficient. Also carbonated or effervescent drinks 
will often be retained when "still" liquids are vomited. 

MEDICAL TREATMENT 

Sodium (or potassium) bromid is often of service in 
these cases. It is best given in one gram (15 grains) 
doses, well diluted, by mouth if possible, if not, by 
rectum, and repeated every two or three hours until 
the vomiting is conquered or the treatment proves 
useless. 

Although bromids appear to be efficient, thyroid is 
not infrequently of use. It should be tried in small 
doses, about 0.20. gm. (3 grains). 

Corpus luteum, best given subcutaneously, is at times 
of value. It is obtained in ampules containing % grain 
of soluble corpus luteum powder in 16 minims of 
physiologic saline solution. One dose a day for a few 
times, then a dose once in five to seven days is often 
sufficient. 

If there is great nervous irritability, often showing 
parathyroid insufficiency, calcium is valuable. 



624 ECLAMPSIA 



DIET 



Liquid diets may be advisable, but frequently a 
patient may retain solid foods and vomit liquids. 

THERAPEUTIC ABORTION 

When all measures have failed to control the vomit- 
ing and before the patient has actually reached a dan- 
gerous condition of prostration, consultation should 
be had and measures should be taken to empty the 
uterus. Naturally, of course, one waits as long as pos- 
sible before doing this. The signs of actual danger 
are the continual rapid decline in weight, declining 
blood pressure with increasing pulse rate, appearance 
of acetone in the urine and a febrile temperature. If 
these signs occur in spite of proper dietetic measures, 
abortion will have to be induced. This should not be 
postponed until the patient is unable to stand the neces- 
sary maneuvers. The written consent of the patient 
and family should be obtained, and it is safer to call in 
an experienced consultant. 

ECLAMPSIA 

There is probably no condition that the medical man 
has to cope with that makes, from prodrome to seque- 
lae, such demands on his capabilities, his judgment, and 
his tact as does this toxemia, for intoxication it is, 
poorly though we may understand it and little as we 
know of its etiology. Having its cause in some dis- 
turbance of the chemistry of either internal secretion 
or metabolic function, or both, its treatment must nec- 
essarily be elimination until an increased knowledge of 
the condition permits it to be corrective. 

The etiology of eclampsia as formulated into a table 
of relative values by Mosher {Jour. Missouri State 
Med. Assn. 16: 69, 1919) follows: 

1. Failure of elimination of toxins. These in the 
early months are doubtless due to the placenta, and in 
the second half of pregnancy doubtless to the excre- 
tions of the fetus. 

2. Infections of various types throw a burden on the 
pregnant woman. 

3. We have an asphyxia of greater or less degree, 
resulting from pressure and from stasis with a decrease 



ECLAMPSIA 625 

of normal power of maternal oxygenation, thus inter- 
fering with lung expansion and with the action of the 
heart. 

Accepting this theory of the production of eclampsia, 
a standardized plan of prophylaxis and treatment has 
been outlined : 

1. Diet which shall be of nonirritating food. 

2. Elimination encouraged by kidney, bowels, skin. 
Intake and output of fluids is a most important routine 
and must be shown in a daily consolidate report. 

3. All foci of possible infection, tonsils, teeth, kid- 
neys and bowels, should be discovered and eradicated. 

4. Deep breathing, by aids to general circulation and 
by fresh air, avoids danger of asphyxia. 

5. Free exhibition of alkali-salts and food anticipates 
acidosis. 

6. Veratrum viride by a system devised to lower 
blood pressure, reduce the pulse and aid diaphoresis. 

7. The emptying of the uterus as a therapeutic mea- 
sure to be done in the way least conducive to shock is 
indicated as soon as prophylactic measures fail. 

When it is possible to take the patient to a hospital, 
this should be done at once, for a case of eclampsia 
can at any moment present conditions which even the 
resources of a hospital, with its trained attendants, find 
difficulty in meeting, and these conditions can change 
with a rapidity which none but institutional resources 
may attempt to meet. Whatever difference of opinioi? 
there may be concerning other features of this condi- 
tion, there can be no question that more cases are saved 
under institutional treatment than under any other, 
and only by reason of their increased facilities. If it 
be impossible to take the patient to an institution, and 
home treatment becomes a necessity, then the first thing 
to do is to prevent self injury to the patient by instruct- 
ing some one present how to hold a towel, cork, or a 
rubber eraser between her teeth, and to keep her on 
the bed. 

EXAMINATION 

A thorough examination should be made, and if 
there are convulsions present or the examination starts 
one, sufficient amount of chloroform may be adminis- 



626 TREATMENT OF ECLAMPSIA 

tered to allow the examination to be completed, and that 
thoroughly, for it is more important to know the exact 
condition present than to start any treatment with an 
incomplete knowledge of the case. 

The examination having been completed, if delivery 
is indicated the cervix can usually be completely dilated 
under chloroform without instrumentation (i. e., with 
the hand), forceps applied, and delivery completed. 
The placenta should generally then be removed, not 
waiting the usual twenty minutes, and the method of 
Crede is preferable. 

Generally there is a tendency to profuse hemorrhage, 
and, the placenta having been removed, the uterus 
should be thoroughly irrigated with hot physiologic 
saline solution and it and the vagina packed with sterile 
gauze. However, the packing being in readiness, it is 
good judgment to wait a few moments before using it, 
to see if the hot irrigating solution provokes sufficient 
contraction to stop the bleeding, for if it does, there is 
avoided the presence of an unnecessary foreign body 
in the uterus. 

Laceration, if present, should generally be repaired 
at once, always if it has caused hemorrhage. If not, 
the patient's condition may occasionally make the post- 
ponement of the repair advisable. 

ELIMINATIVE TREATMENT 

If indications for immediate delivery are not found, 
i. e., if the cervix is not much shortened or not much 
softened, the os undilated, and few or no uterine con- 
tractions (and this last is the most important deter- 
mining factor, since uterine contractions appear to 
excite the eclamptic convulsions) eliminative treat- 
ment should be started. If there is stertorous breath- 
ing, with small pupils, and slow, full, high tension 
pulse, and if the patient be more or less comatose, 
"bleeding" is indicated, and from 150 to 500 c.c. of 
blood should be removed, but whether or not this 
should be replaced with physiologic saline solution only 
the condition of the patient at the time can determine, 
certainly not if there is any edema. If it seems desir- 
able, the quantity of saline introduced should not be 



TREATMENT OF ECLAMPSIA 627 

less than three or four times that of the blood with- 
drawn. Next flush out the colon with saline solution 
and allow 1,000 c.c. or more to remain for absorption; 
provided, of course, that there is no edema. Particu- 
larly should the lungs be carefully examined with this 
in mind. Next, wash out the stomach if possible, 
and if done at all do it thoroughly, leaving in it 0.40 
gm. (6 grains) of calomel, with a little sodium bicar- 
bonate and 10 grains of thyroid. A hot pack may be 
applied to the lumbar region. If there is- vomiting the 
stomach may again be washed out, leaving in it another 
dose of thyroid, and a smaller dose of calomel should 
there be reason to believe that the first dose was 
vomited. This eliminative treatment must be repeated 
at intervals until the uterus can be emptied. If it seems 
inadvisable to wash out the stomach calomel may be 
given by mouth in the dose above referred to. 

COMPLICATIONS 

Bladder distention is common and must be borne in 
mind, catheterization frequently being necessary every 
six or eight hours for several days after delivery. 

After delivery, if a sedative is needed, there is none 
better than a combination of sodium bromid, 2 gm. 
(30 grains), and chloral hydrate, 0.50 gm. (7% 
grains), well diluted and given by rectum. This may 
be repeated in an hour if necessary, but a single dose 
is generally sufficient. Morphin, too, is frequently 
advised and .given, but in such a condition as this 
it would seem contraindicated in practically every 
instance. There is no pain to combat, and usually the 
patient will sleep from mere exhaustion if her "ner- 
vousness" is controlled. 

When delivery is completed the danger is by no 
means over, and a careful watch of the patient is 
necessary, for it must be remembered that the sequelae 
of this condition are numerous and a patient can not 
be called out of danger until at least ten or twelve days 
have passed. 

Should the child survive, it is in all probability also 
toxic. It should be given water freely, and also, per- 
haps, colon irrigation once or twice daily. Prognosis 
as to its survival should be absolutely declined. 



628 MANAGEMENT OF PUERPERAL INFECTION 

PUERPERAL INFECTION 

Though septic infection after parturition occurs 
much less often than even a few years ago, it is still 
sufficiently frequent to necessitate resort to every pos- 
sible method of prevention and to the thorough con- 
sideration of effective but non-meddlesome treatment. 

This infection occurs most frequently intone of two 
general forms. One is a typical blood poisoning or 
sapremia, which is caused by the absorption of toxins 
or decomposition products of substances that are 
undergoing putrefactive or other chemical changes in 
the genital tract. Of course the most frequent sub- 
stances causing such poisoning are retained fragments 
of the placenta or membranes, or, if there is any 
obstruction to the exit of the normal lochia, there 
may be absorption from this. Such poisoning may 
be termed an auto-intoxication or autotoxemia. This 
poisoning may cause more or less rise of temperature, 
but it may not be high, and although an increased 
temperature in the first few days after parturition may 
be due to a bowel infection, to the absorption of bowel 
toxins, to some disturbance of the mammary glands, 
to some bladder or kidney disturbance or, of course, 
to some acute infection to which the patient may have 
been exposed, still, generally, the cause of such fever 
will be found to be in the genito-urinary tract. Slight 
injuries of the uterus, vagina or perineum during par- 
turition may allow absorption of and poisoning by dis- 
charges that would otherwise be innocuous. 

The other more serious cause of puerperal infection 
or puerperal fever is the absorption and circulation of 
pathogenic bacteria. Of these may be mentioned some 
varieties of streptococcus, pneumococcus, staphylococ- 
cus, gonococcus, and perhaps not infrequently the colon 
bacillus. Localized infections and more or less general 
disturbance from the last three of these pathogenic 
germs may not be serious infections as far as the imme- 
diate consequences are concerned, and perhaps could 
hardly be called septic fever. Infections, however, from 
some form of streptococcus and occasionally from the 
pneumococcus are always serious ; the patient is septic 
and is suffering from dangerous septicemia. A puer- 



PREVENTION OF PUERPERAL INFECTION 629 

peral streptococcic infection quite commonly, though 
not always, will show a bacteremia and may have as 
a complication endocarditis, even the malignant type, 
with perhaps associated local lesions such as pneu- 
monias, pleurisy and kidney infection, a pyelitis or a 
localized septic process in the kidney substance. Such 
a general infection is usually associated with more or 
less pelvic inflammation and pelvic tenderness, but is 
commonly without any pelvic abscess or purulent dis- 
charge. 

The prevention of infection before, during and sub- 
sequent to parturition, proper cleanliness and care of 
the patient without meddlesome and obstructive treat- 
ment or methods of treatment, and without removing 
Nature's own protective secretions, are the objects at 
which to aim. 

PREVENTION OF INFECTION 

Most of the preventive measures are too well under- 
stood to require more than enumeration, except that 
the part that infected teeth and diseased tonsils 
play in puerperal septicemia is not recognized. 
Such conditions are a menace, and they should be 
corrected during the pregnancy. The selection and 
preparation of the delivery room, the preparation 
of the patient and of himself are well understood 
duties of the attending physician. The nurse also well 
understands the preparation of herself. A few details, 
however, should be emphasized. The nose of the 
patient should be gently sprayed and cleansed with an 
alkaline or mild antiseptic solution. The mouth and 
throat should be washed with some mild antiseptic 
mouth-wash, and the teeth thoroughly cleansed. The 
nurse should not give the patient a vaginal douche 
unless ordered to do so by the physician. The nurse 
should be free from any purulent discharge, especially 
from the nose, throat or even ears. She cannot be 
too careful in observing the greatest possible cleanli- 
ness in the care of the vulva and the vaginal dis- 
charges, with the use of such antiseptic solutions and 
gauze as the physician directs. If the patient must be 
catheterized, too great care cannot be taken to prevent 
infection of the bladder. 



630 RECTAL EXAMINATIONS 

Although a physician may take every means possible 
for personal disinfection and wear a sterilized gown 
and rubber gloves, it seems, except in isolated 
instances, unjustifiable for him to accept a case of 
obstetrics while he is in charge of a patient who has a 
contagious disease, or immediately subsequent to hand- 
ling such a case, whether it be scarlet fever, erysipelas, 
measles or diphtheria. 

The patient ordinarily should not be given a vaginal 
douche just before parturition. Very frequently one 
vaginal examination by the physician, to determine 
the exact position of the child and the condition of the 
os uteri, is all that is needed. This examination should 
be made after sterilization of the hands and with the 
use of rubber gloves. 

Vaginal examinations in pregnancy should compre- 
hend the determination of the following facts: (1) 
The pelvic size, its normality or abnormality; (2) soft 
parts: their normality or abnormality: (a) the peri- 
neum; (b) the vagina; (c) the cervix and os; (d) 
recognition of tumors in or about the lower segment 
— placenta praevia, etc.; (e) the rectum; (3) the 
fetus: presentation and position; the cephalo-pelvic 
adaptability. 

In labor additional data must be determined: (4) 
The fetus; (a) revisional diagnosis of presentation 
and position, which must be made because many of 
the deviations from the normal are'the products of 
labor; (b) the station of the presenting part; (c) the 
fact of compound presentation, as prolapse of the arm, 
leg or cord; (d) fetal deformities; (5) the effacement 
of the cervix, and dilation of the os; (6) the status 
of the membranes. 

RECTAL EXAMINATIONS 

For most purposes rectal examination yields all of 
the information necessary. In the technic as described 
by Holmes the woman should be given an enema before 
examination. Preferably, she should be on a table, or 
at least she should lie across the bed in the lithotomy 
position, with the buttocks quite to the edge, so the glu- 
teal groove will not be in a depression of the bedding. 
A sterile rubber glove should be employed, for even 
though the finger enters a contaminated cavity it is 



RETAINED PLACENTA 631 

not good practice to use a glove which may have infec- 
tive matter on it. The ringer should be anointed with 
sterile petrolatum or other unguent, and then should be 
passed through the anus slowly and carefully. At the 
same time the other fingers should be flexed in order 
that they may not accidentally enter the vulvar orifice. 
The various movements of the fingers should be slowly 
made, that the minimum of discomfort may be caused. 
Rarely will there be any pain, even if hemorrhoids are 
present; in fact, the average discomfort is no greater 
than when a vaginal examination is made. Generally, 
the rectovaginal septum is so lax that the examining 
finger may move with great latitude. Very possibly 
objections to the method may develop. The danger 
is that the inexpert may allow the fingers or thumb to 
slip within the vulva during certain manipulations. 
This will be entirely obviated by keeping them flexed. 
The method is contraindicated when the termination 
of the labor is imminent, for fear, if haste is neces- 
sary, the attendant might forget to change the glove. 
When there is any delay in a normal labor, any 
apparent malposition, or other complicating distur- 
bance, several vaginal examinations must be made. 

If there is any purulent catarrh of the vagina, espe- 
cially if gonorrhea is present, cleansing and perhaps 
mildly antiseptic douches should generally be used. 
On the other hand, with a normal vagina it seems 
unwise to remove the secretions, which facilitate the 
expulsion of the child and at the same time protect 
the mucous membrane. 

RETAINED PLACENTA 

There is a difference of opinion as to the proper 
management when portions of membrane or of the 
placenta are found by examination of the expelled 
after-birth to have been retained. Most obstetricians 
would leave these retained substances to be loosened 
and expelled by natural processes, when ordinary gen- 
tle manipulation of the uterus does not expel them. 
Others believe that the sterilized, rubber-gloved hand 
should gently clean the vagina, and, if necessary, the 
uterus. The removal of retained portions of the pla- 
centa may prevent unpleasant and even dangerous 
hemorrhage. 



632 TREATMENT OF PUERPERAL INFECTION 

The routine administration of fluidextract of ergot 
three or four times daily for several days after par- 
turition in 1 c.c. (15 minim) doses, is believed by some 
modern obstetricians to aid and hasten involution of 
the uterus. If for any reason ergot is not tolerated or 
is inadvisable, quinin in 0.2 gm. (3 grain) doses twice 
a day may be of benefit in furthering this object. The 
use of pituitary extracts is now a recognized clinical 
procedure in such cases, but they should be given with 
caution as to dosage. However, theoretically normal 
cases require no drugs of this type. 

TREATMENT OF PUERPERAL INFECTION 

If some form of puerperal infection has occurred, of 
course the first decision is as to whether or not it is 
local or general. In a local or pelvic disturbance, with 
more or less rise of temperature but without any symp- 
toms of general infection, the treatment should be con- 
servative and more or less symptomatic. The bowels 
should be carefully attended to, the diet should be sim- 
ple but sufficient, large amounts of water should be 
drunk to dilute all the secretions, and Fowler's position 
should be used more or less continuously to encourage 
drainage. Again, vaginal douches generally should not 
be given. 

Of course the vaginal discharge, or, better, the 
uterine secretion directly obtained, should be studied 
bacteriologically to decide, if possible, what infection 
is present. Blood cultures are the only means at pres- 
ent of accurate diagnosis of the variety of infection. 
The result of this examination may suggest the use of 
an antiserum or a vaccine, if either be deemed advis- 
able. The blood should also be examined for patho- 
genic bacteria. 

STREPTOCOCCAL INFECTION 

If a parturient patient has a sudden chill more or 
less severe, with a rapid rise of temperature which 
persists in some degree and is not intermittent, and a 
rapid pulse, puerperal infection has probably devel- 
oped, unless some serious condition like pneumonia is 
about to occur. Other symptoms of this general strep- 
tococcic infection are: a diminished amount of lochial 
discharge, perhaps even without odor; more or less 



TREATMENT OF PUERPERAL INFECTION 633 

tenderness in the pelvic region; a coated and perhaps 
dry tongue ; bad, perhaps septic, breath ; scanty urine ; 
severe lumbar pains; tympanites; at times yellowing 
of the skin; and later, if the infection progresses and 
becomes serious, possibly delirium. The progress of 
the fever is that of a typical septicemia. There may 
be irregular chills, profuse sweatings and more or less 
leukocytosis. If the lungs, breasts, kidneys and throat 
have been excluded as the location of the cause of the 
temperature rise and onset of symptoms, and if the 
uterus is tender and enlarged, as it generally is, acute 
puerperal streptococci infection is in evidence. 

The insistence here should be on the fact that 
because there is a septic puerperal infection, it is not 
forthwith an indication for a uterine curettage, or 
intra-uterine or vaginal douching or any other severe 
operation. The general treatment just outlined for a 
more localized simple puerperal pelvic infection should 
be carried out, with more or less tepid spongings to 
control the high temperature. The bowels should be 
freely moved each day, large amounts of water should 
be drunk and perspiration should be encouraged, 
though the body should be kept clean by frequent 
warm spongings. 

The heart may be stimulated by strychnin, not more 
than 1/30 grain once in six hours, with caffein (per- 
haps best as coffee) twice in twenty-four hours, if no 
delirium is present. Camphor is another valuable car- 
diac and nervous stimulant and 20 or 30 drops of the 
official spirit of camphor, given properly diluted once 
in four to six hours, is good treatment in these cases. 
In emergencies, one, two or three injections of a sterile 
ampule of camphor solution in oil hypodermically at 
intervals of an hour will, at times, tide over cardiac 
depression. Alcohol may or may not be indicated, 
depending on whether or not the patient 'can take other 
nourishment. It should not be used as a stimulant, and 
the dose should not be large. Whether ergot should be 
given must be decided in each case. The ergot will 
improve the tone of the circulation, but may cause the 
uterus to contract more than is desirable. Digitalis 
should not be used except, perhaps, early in the dis- 
ease, as the inflamed or injured myocardium which 



634 HEMORRHAGE IN PUERPERAL SEPSIS 

results from an infection must not be hurt by the 
strong contractions which are caused by this drug. 

Fowler's position should be maintained to promote 
drainage, often with the use of uterine retention tubes, 
and the Murphy drip may be advisable. 

UTERINE HEMORRHAGE IN PUERPERAL SEPSIS 

If more or less serious uterine hemorrhage occurs, 
or if the discharges from the vagina are exceedingly 
fetid, showing decomposition products in the uterus, 
it may be necessary to institute some operative inter- 
ference. Perhaps the safest procedure is to administer 
an anesthetic and to explore and clean the uterus with 
the finger properly protected. Curettage of an infected 
uterus is serious and may cause serious results, to say 
nothing of the danger of perforating the softened uter- 
ine wall. It may be repeated that, except for serious 
hemorrhage, it is probably rarely advisable to clean out 
the uterus during septic infection. Decomposition will 
generally cause a loosening of foreign and pathologic 
tissues from the walls of the uterus, and they will 
generally be passed out through the vagina. Also, it 
should be remembered that in this septic infection the 
uterine muscle itself is more or less inflamed and 
softened, and contains, as well as the surrounding 
lymphatics, more or less of the infecting germ. Also, 
when the infection is well in progress the bacteria 
are probably in the blood. Severe local measures, 
therefore, do not eradicate the disease and may open 
up other avenues of absorption. It may even be wise, 
in the presence of uterine hemorrhage, to pack the 
vagina first to see if the loosening membrane or piece 
of placenta will come away without actual uterine 
interference. 

It should be urged that intra-uterine injections 
and douches are rarely, if ever, indicated, are gen- 
erally dangerous and may do serious harm. Vaginal 
douches in septic infection, while not so dangerous, 
may also cause harm and should generally be omitted. 
In other words, the pressure in the uterine and vaginal 
cavity should always be negative to the pressure 
in the blood vessels and lymph vessels to promote 



POSTPARTUM HEMORRHAGE 635 

exudation into the parturient canal rather than absorp- 
tion from this canal. There is danger, also, in intra- 
uterine injections of forcing septic matter into the 
fallopian tubes. If, later, a pelvic mass is found, 
whether hematoma or abscess, hot vaginal douches may 
be allowable and of value in promoting absorption or 
in hastening localization for vaginal incision and 
evacuation. 

If there is more or less peritoneal inflammation and, 
therefore, pain, morphin is indicated, as a patient 
should not be allowed to suffer pain, for depression 
from acute pain may be the last straw to stop an 
already weakened heart. Local applications to the 
lower part of the abdomen in the shape of turpen- 
tine stupes or alcohol fomentations may sometimes be 
of value as counterirritants. Warm applications, as 
flaxseed or poultices, may give some comfort and 
prevent the necessity of giving much morphin. They 
often cause a relaxation of the muscular tissues and 
lessen the irritation and tension. Of course such 
treatment is purely symptomatic and entirely non- 
specific. If serious infective localization occurs in 
the pelvis, more serious operative interference may be 
necessary. 

In recovery from this very dangerous infection the 
convalescence is long and tedious, and months generally 
elapse before there is a return to normal health. 

POSTPARTUM HEMORRHAGE 

ETIOLOGY 

The causes in general may be summed up as : Those 
which interfere with uterine contractions or cause 
relaxation of the uterine muscle; lacerations of the 
parturient canal; partial or complete retention of the 
placenta, and diseases of the blood or blood vessels. 
The management of the condition includes adminis- 
tration of ergot ; removal of uterine contents ; repairs 
of lacerations; massage of the uterus; hot intra- 
uterine douches; packing the uterus; application of 
hemostatics or administration of systemic vasocon- 
strictors. 



636 TREATMENT OF POSTPARTUM HEMORRHAGE 
PROPHYLAXIS 

Avoid precipitate labors. Avoid protracted labors. 
Avoid a surplus of anesthesia in slow labors; chloral 
(one gram, repeated in an hour if necessary) is prefer- 
able. If there is hemophilia, give a calcium prepara- 
tion for three months prior to delivery. At the onset 
of labor see that the bladder and rectum are empty, 
and as soon as the head is born ergot should be given 
(preferably by the hypodermic syringe), and the uterus 
massaged to stimulate contractions. Pituitary extract 
may be given cautiously. 

If hemorrhage begins during the period between the 
birth of the child and the expulsion of the placenta, 
and without evident relaxation of the uterus, it may be 
due to a partial separation of the placenta or to the 
fact that the placenta is separated but still within the 
uterus. 

TREATMENT 

Hemorrhage immediately following the birth of the 
child may be from the circular artery of the cervix; 
from a lacerated vagina, or from a lacerated perineum. 
In such cases, with the use of the speculum and a con- 
stant stream of water to wash away the flowing blood, 
immediate repair of the laceration is usually easy, and 
correctly placed stitches will stop the hemorrhage. 

If the bleeding does not amount to much more than 
oozing, swabbing with epinephrin solutions may be 
effective. 

The Crede method of expulsion of the placenta will 
usually stop the flow by removing the obstacle, and 
will stimulate the uterus to contract. Failing thus to 
remove the placenta, the necessity of manual removal 
should be considered. 

The placenta having been born, if the hemorrhage 
continues and the uterus is soft and flabby, contrac- 
tion of that organ is the end aimed at. This may be 
secured by continued manual stimulation from without 
and the use of pituitary extract. 

If the hemorrhage still continues, Bryan, Philadel- 
phia, advises the "bimanual manipulation," usually 
accomplished "by passing two fingers of the right hand 
high up into the vagina, along the posterior wall, press- 
ing the lower segment and cervix forward toward the 



DYSMENORRHEA 637 

symphysis pubis, at the same time passing the fingers 
of the left hand deep in between the umbilicus and the 
uterus so that the hand on the outside, the fundus rest- 
ing in the palm of his hand, may be pushed downward 
and forward against the pubes, thus forming a sort of 
temporary anteflexion." 

When these methods fail, the next thing to do is to 
pack the uterus. The volsella forceps are preferable 
for this, as there is little danger that the cervix will 
contract so as not to admit them, and the ordinary 
uterine dressing forceps are sharp enough at their 
points to admit an element of danger from the pos- 
sibility of their being pushed through the fundus. The 
packing may remain in the uterus for from six to 
twenty-four hours, and when it is removed another 
packing should be ready to replace it, if necessary. 
These packs -may be moistened with gelatin or serum, 
though this is generally not necessary. 

After the hemorrhage has ceased the patient requires 
rest; injection of saline per rectum; perhaps a blood 
transfusion or transfusion of some of the solutions 
suggested under the treatment of shock. 

DYSMENORRHEA 

The treatment of dysmenorrhea should, of course, 
vary with the indications as based on the underlying 
condition. Cases should be analyzed as to the exis- 
tence of defective development of the genital organs; 
abnormal ovulation; in some cases the cause must be 
sought in the glands of internal secretion. 

The condition known as vagotony may be at the basis 
of the menstrual pain, or local or radiating neuralgias 
may be responsible. In still another class of cases 
spasmodic contraction is the source of pains ; defective 
development of the uterus may be the basis for this 
or it may be maintained or aggravated by pain in the 
ovaries. The spasm may be more painful when there 
is any mechanical hindrance to distention of the ovaries 
and uterus during menstrual congestion. 

Mosher believes that dysmenorrhea is largely a 
functional disorder, congestive in type and produced 
by (1) the upright position; (2) alteration of the 
normal type of respiration by disuse of the diaphragm 



638 CAUSES OF DYSMENORRHEA 

and of the abdominal muscles; (3) the lack of gen- 
eral muscular development; (4) inactivity during the 
menstrual period; (5) psychic influences. She shows 
how the upright position with the valveless vena cava 
causes uterine congestion which tends to become exag- 
gerated when the abdominal muscles are lax, when 
costal breathing is employed and by clothing which 
interferes with the action of the respiratory muscles. 
Mosher has corrected these conditions in many cases 
by the following method: "All tight clothing having 
been removed, the woman is placed on her back, on 
a level surface, in the horizontal position. The knees 
are flexed and the arms placed at the sides to secure 
relaxation of the abdominal muscles. One hand is 
allowed to rest on the abdominal wall without exert- 
ing any pressure to serve as an indicator of the 
amount of movement. The woman is then directed to 
see how high she can raise the hand by lifting the 
abdominal wall ; then to see how far the hand will be 
lowered by the voluntary contraction of the abdom- 
inal muscles, the importance of this contraction being 
especially emphasized. This exercise is repeated ten 
times, night and morning, in a well-ventilated room, 
preferably while she is still in bed in her night cloth- 
ing. She is cautioned to avoid jerky movements and 
to strive for a smooth, rhythmical raising and lower- 
ing of the abdominal wall." The results have been 
that the pain has been lessened in many cases and 
wholly removed in a large number. The desirability 
of more activity is noticed but she cautions against 
excess, especially in the athletics of college training. 
A hopeful mental condition is important, and it is 
unfortunate that pain or disability is so commonly 
expected. 

In those types of dysmenorrhea due to vagotony, 
when the autonomic nervous system is in a state of 
hypertonicity, the pronounced spasticity from over- 
stimulation of the vagus brings on pain at menstrua- 
tion and atropin wards this off or cures it. In small 
doses atropin has a stimulating and in large doses 
a paralyzing action on the sympathetic nervous sys- 
tem, and instances of failure to relieve the dysmenor- 
rhea are probably due to incorrect dosage. Atropin 



TREATMENT OF DYSMENORRHEA 639 

arrests the pains by paralyzing the nerve terminals 
belonging to the vegetative nervous system. The 
menstrual discharge increases in amount after taking 
the atropin, possibly from relaxing the spasmodic con- 
traction of the vessels or of the uterus or both. 

Osborne, Dalche and others have discussed the use 
of thyroid and ovarian extract in dysmenorrhea. 
When no definite cause may be found a course of 
thyroid treatment may restore the balance between the 
internal secretions. Frequently it is effectual in regu- 
lating menstruation, increasing the menses to normal 
proportions and without abnormal pain. Small doses 
of "pulverized thyroid, 0.025 to 0.05 or even 0.1 gm. 
a day, may be given, keeping this up for a month or 
more to get the full benefit of its stimulating and regu- 
lating action on the functioning of the ovaries. The 
patient must be kept under close supervision during 
the course, suspending the organotherapy if the pulse 
goes over 100, or at least materially reducing the dos- 
age. After the first month the thyroid treatment is 
continued only during the ten days preceding the date 
of menstruation. Sometimes it is better to alternate 
ovarian and thyroid treatment, thyroid in the morning 
and ovarian tissue at evening, or give the ovarian 
treatment continuously for three days and then the 
thyroid continuously for the same length of time and 
then resume the ovarian treatment. 

GENERAL TREATMENT 

To relieve severe pain during dysmenorrhea sodium 
bromid may be given. The salicylates may be pre- 
scribed; perhaps 10 grains three times a day of 
sodium salicylate. Opium is contraindicated because 
of its habit-forming possibilities. 

Macht has suggested the use of benzyl-benzoate in 
this disease. He used a 20 per Cent, alcoholic solution 
of the drug flavored with some carminative, giving a 
dose of from 10 to 30 drops in cold water. Litzenberg 
(Jour. A. M. A., 73:601, 1919) found that patients 
complained bitterly of the unpleasantness of this solu- 
tion, especially the aftertaste, so Professor Hirsch- 
felder made up a 20 per cent, emulsion with acacia in 
aromatic elixir of eriodictyon which proved a much 
more pleasant medicine to take. 



640 ASPHYXIA NEONATORUM 

In dysmenorrhea not quite as complete relief as 
desired was secured with the dosage recommended by 
Macht, so the dose was increased to 1 teaspoonful and 
finally to 2 drams given every two hours. No bad 
effects followed from this greatly increased amount, 
unless an occasional case of vomiting and rarely a 
feeling of weakness might be so attributed. 

The prescription used is given herewith. 

Gm. 

I£ Benzyl benzoate 10 

Mucilage of acacia 5 

Aromatic elixir of eriodictyon . 35 

Give from % to 2 teaspoonfuls, according to necessity. 

The drug may also be obtained in soft capsules, sev- 
eral preparations being listed in New and Nonofficial 
Remedies. 

Relief may be obtained from hot applications on the 
feet, front of the legs and inner side of the thighs, with 
moist heat to the abdomen. The patients should guard 
against constipation. The search for the cause should 
be most thorough and if the condition persists and no 
cause can be found one should not hesitate to seek 
special advice and consultation. 

ASPHYXIA NEONATORUM 

This condition is one which every obstetrician should 
be prepared to treat promptly. In milder degrees it 
occurs in a large proportion of deliveries. In its more 
severe forms it fortunately is less common. 

The more common causes of the condition are pre- 
mature detachment of the placenta; prolapse of the 
umbilical cord ; excessive use of chloroform, of chloral, 
or of morphin administered to the mother to diminish 
the pain of labor; or large doses of ergot given during 
the second stage of labor to increase the contraction of 
the uterus; extreme compression of the head of the 
child owing to the unusually severe contractions of 
the uterus separated by brief intervals; obstruction to 
the passage of the head by narrowness of the pelvis; 
compression of the head by unskilled delivery with 
forceps; compression of the after-coming head in the 



PREVENTION OF ASPHYXIA 641 

delivery of breech cases; and compression of the 
cord through its being wound around the child's neck, 
or through its being drawn into a knot. 

PREVENTION 

The preventive treatment naturally is based on a 
consideration of these causes. In instrumental deliv- 
ery great pressure on the head of the child should be 
avoided, and the traction should be made intermittent 
and not continuous. If there is prolapse of the umbili- 
cal cord, it should be replaced, the woman placed in 
the knee-chest position, and every effort made to 
retain it until the head has become engaged in the brim 
of the pelvis. In all severe labors preparation should 
be made before the birth of the child to apply suitable 
treatment in case it should be born in a condition of 
asphyxia. These preparations should include a baby's 
bath tub with a supply of warm water conveniently at 
hand, a bowl of cold water, a warm woolen blanket, 
a small piece of gauze, and a hypodermic syringe. 

A soon as the child is born it should be promptly 
slapped repeatedly on the buttocks and back. The 
mouth and throat should be wiped out with a piece of 
gauze so as to clear out any blood, mucus or amniotic 
fluid which may be there. If this does not promote 
the reflex action of breathing, the cord should be felt 
to see if it is pulsating. 

By this time one has had an opportunity to inspect 
the surface of the child to see whether the condition is 
one of asphyxia livida, in which the skin is congested 
and livid and the reflexes are maintained; or whether 
the condition present is asphyxia pallida, in which the 
surface is pale and cold, the muscles are relaxed, and 
the reflexes are absent. The treatment should vary 
somewhat according to which of these two conditions 
is present. 

ASPHYXIA LIVIDA 

If the condition is one of asphyxia livida, with con- 
gestion of the skin, there is some difference of opinion 
as to whether the cord, if it is pulsating, should be at 
once cut and a small amount of blood allowed to escape, 
or whether it should not be cut until later. Probably 
it is wiser to postpone this for five or ten minutes. In 



642 ARTIFICIAL RESPIRATION 

the meantime the child should be grasped by its feet 
in the left hand of the physician and held in an inverted 
position while several light blows are administered on 
the buttocks, shoulders and chest, in order, if possible, 
to expel any more blood or mucus which may be in 
the larynx and trachea. This position should be main- 
tained for only a few seconds, 

ARTIFICIAL RESPIRATION 

Next, the Byrd Dewey method of artificial respira- 
tion should be tried. This consists in placing the palm 
and fingers of the right hand under the child's shoul- 
ders, while the index finger and thumb support its 
head, the left hand being placed under the hips. With 
the child in this position, by raising the radial sides 
of the hands, the legs and knees of the child are 
brought up onto its chest and the chest is compressed 
so that the air is expelled ; then reversing this position 
and allowing the head and shoulders to fall backward, 
the chest is expanded and the air drawn in. These 
maneuvers should be repeated at intervals of about 
five seconds, so that the procedure will be repeated 
from ten to fourteen times in a minute. If the cord 
is of average length, this -can be done before the 
cord is cut. 

If the cord has not been cut before, it should be 
now, and the child at once placed in a tub in which 
water of a temperature between 100 and 105 F. has 
been placed. This will promote the circulation in the 
skin and prevent the body from being chilled, and 
further treatment may be carried out. 

The next method of encouraging respiration is that 
known as the method of Laborde. This consists in 
grasping the tip of the tongue either with the thumb 
and finger, with the aid of a piece of gauze, or with 
forceps, and drawing it forward and then letting it fall 
backward. This should be repeated from ten to four- 
teen times a minute, and may be continued for one 
or two minutes. While this is being done the child 
should lie with the head drawn slightly backward, or 
on one side. 

If the child does not breathe by this time, it is 
well to take it out of the warm water and plunge it 
into a bowl of cool water of a temperature of from 



TREATMENT OF ASPHYXIA 643 

65 to 75 F. It should be allowed to remain here but 
a few seconds, and then placed back in the warm 
water. In the meantime it should be vigorously 
rubbed, but at the same time caution should be used 
not to rub it harshly for fear of doing serious damage 
to the skin. 

In some cases it has been found that inserting the 
tip of the little finger into the anus will stimulate the 
reflex action of breathing. 

Another method not infrequently employed is that 
known as the method of Schulze, which consists in 
standing back of the child, placing the palmar surfaces 
of the three outer fingers under its shoulders, the index 
finger of each hand under the axilla, and the thumbs 
on the chest, with the ball of the thumb resting on each 
side of the child's head. The physician thus grasping 
the child and then standing erect, gradually swings the 
child forward and upward in front of himself until it 
is above his head. In this position the child's thighs 
and legs fall against its chest, which is thereby com- 
pressed and the air forced out. Then swinging the 
child back into the original position, the chest is 
expanded, and the air enters. This may be repeated 
at intervals of five or six seconds, so that it will be 
done from ten to fourteen times in a minute. This is 
a method which presents more or less of the appear- 
ance of violence, and hence it is not always practicable 
to do it in the presence of the friends of the patient. 
It should also not be practiced if there are fractures 
of any of the bones, or if the child is especially feeble, 
or has been born prematurely. 

If difficulty has been experienced in clearing the 
larynx and trachea of mucus, a small soft catheter may 
be inserted through the larynx into the trachea, and 
any mucus present drawn out, either by the physician 
himself or with the aid of a syringe or aspirator. 

If other methods fail, it is recommended to blow air 
into the lungs of the child. This may be done by the 
socalled mouth-to-mouth method in which, a piece of 
gauze being placed over the mouth of the child, the 
physician filling his cheeks with air expels it into the 
mouth of the child, at the same time holding the 
child's nose. This method is somewhat inexact, as 



644 ASPHYXIA PALLIDA 

much of the air frequently goes into the stomach, but 
some of it goes into the lungs, if they are not already 
distended. After blowing air into the lungs, the chest 
should be compressed so as to drive it out again. 

An effective method of resuscitating asphyxiated 
infants is that of Meltzer and Auer, by tracheal insuf- 
flation. A rubber catheter is passed into the trachea as 
far as the bifurcation and air is pumped into the lungs 
by means of a rubber bulb, the pressure being regulated 
by a mercurial manometer connected with the appara- 
tus. The return air escapes alongside the catheter. 

A few drops of ammonia on a piece of linen may be 
held under the child's nose, but not too closely, with 
the hope that this will stimulate respiration and, as it 
sometimes does, muscular contraction. A hypodermic 
injection of a drop of tincture of belladonna or 1/1,000 
of a grain of strychnin may be given. 

If by the time all these methods have been tried the 
child has not commenced to breathe, the physician 
naturally wonders how long he ought to continue his 
efforts. The answer to this question depends largely 
on the condition of the heart. He should continue his 
efforts* at artificial respiration and external stimulation 
as long as the heart beats. After it has been impos- 
sible for five minutes to detect any pulsation of the 
heart, it is useless to continue any further efforts at 
resuscitation. 

If the efforts have been successful and the child 
commences to breathe, even if the breaths are taken 
at long intervals, one should avoid an over-anxiety in 
interfering with the natural performance of the func- 
tion by the child. Once it has begun to breathe it 
probably will continue to breathe and the breaths will 
increase in depth and frequency until they become 
normal. 

ASPHYXIA PALLIDA 

Turning now to the other class of asphyxia neo- 
natorum, viz., asphyxia pallida, in which the reflexes 
are absent and the heart is weak; if the cord is not 
pulsating, it should be immediately cut and the child 
placed in a tub of warm water. If, however, it is 
pulsating the child should not be separated from the 
mother until the pulsation has ceased. The same 



ASPHYXIA PALLIDA 645 

methods are applicable in these cases as in the others, 
except that the more violent ones had better be omitted 
and all efforts concentrated on the employment of the 
milder methods, especially the rhythmical traction of 
the tongue as practiced by Laborde. Especially is it 
important to maintain the temperature of the child, 
and the water in the warm bath should be maintained 
at a temperature of 100 or a little higher by adding 
fresh warm water as fast as the water in the tub 
becomes cool. 

After the child has gained the ability to breathe 
regularly it should be carefully watched for several 
days, for if there has been difficulty in relieving the 
asphyxia, there is danger that it will become feeble 
and die in the course of a few days. It should be well 
wrapped up, and the external heat should be main- 
tained. The milk should be drawn from the mother's 
breast and fed to it with a medicine dropper, if it is 
not able to take hold of the breast and draw for 
itself. 



DISEASES OF INFANCY 



INFANT MORTALITY AND FEEDING 

The amount and extent of infant mortality have 
been estimated in various ways. In general, all seem 
to agree that approximately 15 per cent, of all chil- 
dren born die before they are 1 year old. As to the 
causes of fetal mortality, Williams (Jour. A. M. A.I 
Jan. 9, 1915, p. 95) analyzed 705 fetal deaths which 
occurred in 10,000 consecutive admissions to the obstet- 
rical department of Johns Hopkins Hospital. Included 
in this list are all those who died immediately after 
birth up to those who lived two weeks and died. Of 
this class syphilis was responsible for 26 per cent.; 
unknown causes, 18 per cent. ; dystocia, 17 per cent. ; 
various unpreventable complications, as hemorrhagic 
diseases, cord infection, status lympha'ticus, strangula- 
tion by loops of cord, about 1 1 per cent. ; prematurity, 
7 per cent. ; toxemia, 6.5 per cent. ; deformity, inani- 
tion, criminal suffocation, placenta praevia, etc., all 
less than 5 per cent. The cure for this type of infant 
mortality is proper prenatal care. This prenatal care 
means that the physician must examine his cases, make 
regular urine examinations, see that the expectant 
mother secures a proper diet, correct and sufficient 
exercise and a proper hygiene. 

Approximately one third of the deaths during the 
first year are due to congenital malformations, defor- 
mities and weaknesses ; another third to diarrheal dis- 
eases; a little less than one fourth to respiratory and 
tuberculous diseases; and the remainder to other 
diseases. 

It is toward the diminution of the number of deaths 
from diarrheal diseases that preventive efforts are con- 
spicuously directed. A very large proportion of these 
deaths occur during the hot weather between July 1 
and October 1, and are directly traceable to improper 
feeding and improper food. Hence arises the great 
importance of the problem of feeding the infant. 

When the fact is recalled that the milk of different 
animals varies in composition, it is not necessary at 






: 



BREAST FEEDING 647 

the present day, and in the present advancement of 
scientific knowledge, to enter on any argument to 
attempt to prove that the milk of the human mother 
is the very best food for the human infant during the 
early months of its life. Every woman, therefore, 
who gives birth to a living child, unless she is suffer- 
ing from some serious disease, should nurse her baby. 
This course is not only decidedly advantageous to the 
mother, but is also of the greatest importance to the 
child. 

BREAST FEEDING 

No artificial method of feeding has ever been devised 
which is as beneficial as nursing at the breast of a 
healthy mother. Unfortunately, many mothers object 
to performing this duty on various grounds; some 
because they have sore nipples and nursing is painful ; 
others because the baby will not take the nipple, and 
therefore is given a bottle instead; others because they 
think that their milk is not adequate in quantity or of 
sufficiently good quality to properly nourish the baby ; 
others because they think that their health is being 
undermined by the drain on the system incident to lac- 
tation; and still others because they are unwilling to 
give up social pleasure so as to be available to nurse 
the baby every three or four hours. All these condi- 
tions should be taken into account by the physician, 
and such as are present in any individual should, if 
possible, be removed. He should emphasize to the 
mother the great importance, both to herself and to her 
child, of providing the natural food from her own 
breast for her baby. He should also give explicit direc- 
tions to the nurse in regard to the care of the breasts 
and nipples so that the latter may not get sore, a con- 
dition which not infrequently is accompanied by serious 
diminution of the flow of milk. 

CARE OF THE NIPPLES 

Inappropriate clothing and nonuse render the nip- 
ples soft, and they have to be toughened. Air and 
water are what is required. The clothing should be 
loose and light over the breasts ; they should be given 
^air baths during the day, and several times during the 



648 TECHNIC OF BREAST FEEDING 

day, at least on rising and retiring, the whole breast 
should be sponged with cold water. If the nipples are 
particularly tender they can be dabbed in the morning 
with a little alcohol to harden them, and at night a 
little glycerin or tannin-glycerin applied to make them 
pliable. 

At the first sign of smarting, indicating a crack in 
the nipple, it should be treated with alcohol without 
the slightest delay, or touched with a silver nitrate 
pencil. Salves and moisture undo what has been 
accomplished in toughening the nipple. 

TECHNIC OF BREAST FEEDING 

The young, inexperienced mother needs to be 
instructed in the most elementary details concern- 
ing nursing. She is shown how to retract the paren- 
chyma of the breast from the nipple so that the infant's 
nose will not be buried in the mamma and respiration 
will not be constricted in this manner. If she trains 
the baby to grasp the areola as well as the nipple, the 
milk flows more freely and the nipple is less liable to 
be traumatized and rendered painful. The nipples 
should be kept scrupulously clean, and may be washed 
before nursing, using plain water. The most impor- 
tant stimulus to lactation is vigorous sucking by a 
healthy infant. 

The interval for feeding should never be under two 
hours, practically never under three hours. Carlson 
and others have shown that the onset of hunger in 
infants occurs in from two and one-half to three hours 
The three-hour interval is apparently that approved by 
most authorities, although many good pediatricians 
insist that four-hour intervals are correct, especially 
after the first few months. All these matters, however, 
should be especially considered with the needs of the 
individual infant and mother in mind. A night feeding 
between 10 p. m. and 6 a. m. is ordinarily unnecessary. 

The nursing mother should have axercise, plenty of 
rest, and be free from worry if possible. Too fre- 
quent feeding of the infant will result in continual 
dilatation of its stomach and in the production of 
intestinal disturbances. The proper correction of these 



COLIC 649 

gastrointestinal upsets lies with the mother. If neces- 
sary she may be given a tonic and constipation should 
be corrected with cascara or some mild laxative. 

In the composition of the milk, the fats and proteins 
are the constituents apt to be at fault. In cases in 
which the fat is too small in amount, the mother 
should take cow's milk, cereals, fats, and plenty of 
exercise, fresh air and sleep. Nursing should be less 
frequent when the fat percentage is too great. In such 
cases the child may have colic after feeding, it may 
have facial eczema, or seborrhea of the scalp; it 
vomits sour mucus, the stools smell sour and irritate 
the skin, and on staining with Sudan III particles of 
fat are visible in large quantity. The reduction of fat 
excess is difficult. The infant should, as has been 
stated, be fed less frequently. The diet of the mother 
should be modified to limit fat-producing substances, 
the chief of which are the fats themselves. It may 
be necessary to feed only that portion of the breast 
milk containing small quantities of fat. The breast 
pump may be used thus to eliminate the first or last 
part of the feeding to obviate undesirable surplus of 
any constituent. 

If protein is the disturbing element, causing colic, 
constipation or diarrhea with mucus stools containing 
tough white curds, in shape of bean, or peanut-like 
masses, the mother is probably leading a sedentary 
life and eating much meat and eggs and highly sea- 
soned food with lack of fruit and vegetables. 

COLIC 

In the foregoing are found the causes, and, in a 
large measure, the prevention of colic. An attack 
of colic is unmistakable: the child cries violently, the 
abdomen is hard and distended, the knees are 
drawn up, and the hands and feet, which are never 
still, are cold from the intense intestinal conges- 
tion. The trouble may be either in the stomach, com- 
ing on soon after nursing, or in the intestines an hour 
or two later. Most mothers know all the mechanical 
remedies, such as hot applications, enemas, turning 
the baby over on his stomach, or holding him against 
her shoulder. It is often necessary to stop feeding 



650 DIARRHEA 

entirely for twenty-four hours. Frequently, diluting 
the milk by giving water, lime-water, or barley-water 
before nursing helps. Nursing a few minutes and 
stopping a short while, or the use of the nipple shield 
may be beneficial. Good results have been secured 
with peptonizing powder dissolved in warm water and 
given before each feeding. Carminatives, milk of 
magnesia, sodium bicarbonate, magnesium carbonate 
and bismuth subcarbonate may often be used to advan- 
tage. 

DIARRHEA 

As pointed out again recently by Grulee {Jour. Mis- 
souri State Med. Assn. 16: 366, 1919), it cannot be too 
strongly impressed on the profession that diarrhea is 
not a disease but a symptom; that it is perhaps the 
most frequent symptom which we encounter in infancy ; 
that it is apt to occur in almost all of the disease proc- 
esses at this age, especially in acute diseases. The 
question of its importance depends on the relation of 
the severity of the diarrhea to the general condition 
of the patient. A slight diarrhea with a high fever 
means almost invariably that the condition is not of 
gastro-intestinal origin. And, on the other hand, a very 
severe diarrhea with high fever usually points to the 
gastro-intestinal tract as the origin of the condition. 

LACK OF MILK 

When milk is insufficient in quantity the breasts are 
flabby, and the baby does not seem satisfied. "Instead 
of nursing fifteen or twenty minutes and falling asleep, 
some fret and whine and pull at the nipple often for 
half an hour, while others give up entirely for a few 
minutes and then try again. The weight remains sta- 
tionary or shows only a slight gain. There is no colic, 
no vomiting; the stools are scant, often with an olive- 
green tinge, and contain no undigested food. How- 
ever, unsatisfactory weight may be the result of over- 
feeding as well as underfeeding. It should be remem- 
bered, too, that weight fluctuations are common in 
infants, just as in adults; therefore, the food should 
not be changed until it has been found that for two 
or three weeks there has not been an average weekly 
gain of from at least 3 to 4 ounces. With an abun- 






POSTURE AND DIGESTION 651 

dance of good nourishing food for the mother, regular 
habits for the mother and baby, and mixed feeding, if 
necessary, in underfed babies, we always expect favor- 
able results." 

CONTRAINDICATIONS 

Contrary to general opinion, menstruation is not a 
cause for stopping of nursing. According to Hess and 
other pediatricians, not infrequently the quantity of 
milk is somewhat lessened during menstruation, and 
this may result in the infant becoming fretful, due to 
insufficient quantity of the feeding. "Under no cir- 
cumstances," says Hess, "should menstruation be con- 
sidered an indication for weaning." Tuberculosis and 
a new pregnancy should be taken as sufficient cause. 
If milk is insufficient, breast nursing should be alter- 
nated with the feeding of correct milk mixtures. 

INFLUENCE OF POSTURE ON DIGESTION 

Smith and LeWald (Amer. Jour. Dis. Child., 1915, 
April, ix, p. 261) have shown that air is swallowed 
with the food by many if not by all infants. The erect 
posture favors eructation of this air; the horizontal 
prevents it. The horizontal posture, by preventing 
eructation, is an important cause of vomiting, colic, 
indigestion and disturbed sleep. The following routine 
should be followed in feeding every infant: Before 
feeding, the infant should be held upright to allow the 
escape of any gas present in the stomach. Immediately 
after feeding the infant should again be held up 
against the shoulder of the mother or nurse. He may 
be patted on the back or gentle pressure may be made 
on the epigastrium to encourage eructation of the 
swallowed air. It may be necessary to interrupt the 
feeding one or more times to hold the child upright to 
eructate, in cases in which an excessive amount of 
air is swallowed. After the gas is eructated the child 
should be put down to sleep, preferably in the prone 
position and with the head of the bed raised. If rest- 
less he may he taken up after a short time to see if 
there is more air in the stomach. . Habitual tongue- 
suckers need to be held up several times between feed- 
ings, as they constantly swallow air. Other suckling 
habits must be prevented by mechanical restraint. 



652 SUPPLEMENTARY INFANT FOODS 

Feedings should be given at as long intervals as pos- 
sible, depending on the gastric capacity and the total 
daily requirements. A feeding should not be taken too 
slowly. From five to ten minutes are enough as a 
rule; fifteen minutes should be the maximum time at 
bottle or breast. The importance of posture and the 
wrong teaching given to physicians and nurses in the 
past warrant the emphasis laid on so simple a matter. 

SUPPLEMENTARY FOODS 

The choice of supplementary foods is a difficult 
problem. Most proprietary foods are high in carbo- 
hydrate content. They may sometimes be utilized as 
sugars in the modification of fresh milk. Cow's milk 
should be the basis, but when it fails, even after 
diluting, boiling or peptonizing, one should persist 
until sure that no food will agree as long as the baby 
takes the breast. As a temporary expedient, some of 
the approved proprietary foods may be successful, 
especially when the fat content in mother's milk is 
high. Constipation is better controlled by mixed feed- 
ing than by any other means; give a bottle of cow's 
milk with a high percentage of fat, or some laxative 
food, or frequently milk of magnesia in one artificial 
feeding daily. After seven months it is best to use 
mixed feeding in all cases, with the idea of gradually 
training the infant stomach for the new food that 
weaning time will add. A 3 p. m. bottle without the 
nursing should be given, and later an additional one 
at 10 a. m. Frequently at about 6 months, the 
mother's milk begins to grow less, and the fat per- 
centage high, and the baby shows signs of fat indi- 
gestion. Under such a condition a bottle of milk 
containing a low fat mixture should be given. When 
from any cause the mother's health is impaired and 
the milk is consequently below the standard, the needs 
of the infant may be temporarily supplied by the addi- 
tion of artificial foods, thus giving the mother time to 
recuperate. 

WEANING 

No age limit can be set for weaning. By one year 
a normal baby will ordinarily wean himself if gradu- 
ally a bottle of milk mixture is substituted for breast 



WET NURSING 653 

feeding, and cereals, toast with butter, broth, beef 
juice and coddled egg are added, depending on the 
growth and development of the child. Should the 
weaning time fall during the summer months, how- 
ever, it is best to continue the mixed feeding until 
cool weather. At 9 months the average infant weighs 
about 17 or 18 pounds. Few mothers have milk that 
will furnish sufficient nourishment for a child of this 
size. In the majority of instances, where mothers 
attempt to nurse their babies after 7 months, to the 
exclusion of other foods, they do so at the risk of 
grave malnutrition or rickets. 

WET NURSING 

If the mother cannot or will not nurse her own baby, 
the next best resource is a good wet-nurse. By this 
means the baby is supplied with human milk, and if 
the nurse is healthy, and was delivered at approxi- 
mately the same date as the child's own mother, the 
substitute will usually prove very satisfactory. But 
practically, this method of feeding a baby is applicable 
to only a very limited number of the babies who are 
denied nourishment at their mother's breast. 

cow's MILK 

When human milk is unobtainable, the best substi- 
tute, from a practical point of view, is cow's milk, 
because it can generally be obtained in abundance in 
a more or less fresh state. Its composition is well 
understood, also the respects in which it differs from 
human milk. Like everything else in common use, 
it varies greatly in quality, and some- of these varia- 
tions are intimately associated with unhealthfulness. 
Years ago consumers were especially disturbed by the 
abnormal proportion of water which many specimens 
of milk contained, and which was alleged to have been 
introduced surreptitiously by the producer or the 
dealer. This adulteration has largely been prevented 
by state legislation and the activity of local health 
boards. 

With increasing knowledge of fermentation and 
putrefaction, and the relation of bacteria to these proc- 
esses, it became evident that milk, although kept free 



654 CARE OF COW'S MILK 






from intentional dilution and contamination, readily 
underwent deleterious changes under the influence both 
of its inherent tendencies and of extraneous contami- 
nating matters accidentally introduced into it. At 
present the most important cause of the deterioration 
of milk and the development of deleterious qualities 
in it appears to be the growth of bacteria. It seems 
to be practically impossible, even with the greatest 
care, to secure milk which is entirely free from bac- 
teria, even when it is first drawn from the cow. Pos- 
sible sources of contamination are dust and dirt in the 
air of the barn or dairy, and manure and other dirt 
loosely adherent to the hair of the cow, the hands and 
the clothing of the milker, and utensils used in the 
transportation of the milk. 

It would consequently appear that the work of 
extracting the milk from the cow should be conducted 
in the same way as an aseptic surgical operation. 

Practically, most milk which is furnished to the 
consumer contains an abundance of bacteria, and an 
important practical problem is how their injurious 
effects may be avoided. It has been found that the 
growth of bacteria is prevented by a low temperature. 
Therefore, it is apparent that all milk should be cooled 
to a temperature not above 50 F. as soon after it is 
drawn from the cow as possible, and it should be kept 
at a temperature not above 50 F. until it is used. 

Through appointment of milk commissioners it is 
now possible to secure certified milk from certified 
cows. The number of bacteria and their virulence 
have been checked and such milk if fresh may be 
assumed to be safe. 



STERILIZATION AND PASTEURIZATION 

Not so very many years ago the advice was given 
to obviate infected milk by "sterilizing" it by boiling. 
It was even advised to sterilize all the milk which was 
fed to infants. This was soon found to be objection- 
able (1) because it altered the taste and made the 
milk less palatable, and (2) because exposure to such 
a degree of temperature as was necessary to boil milk 
produced such changes in it, including a destruction of 
the enzymes, that it was not a good food for infants. 









THE NERVOUS CHILD 655 

Next, in order to avoid this interference with the 
digestibility of the milk, it was proposed to subject the 
milk to such a temperature, below the boiling point, 
as would inhibit the growth of bacteria and would not 
make other objectionable changes in it.* This tempera- 
ture was found to be about 140 F., and the process of 
heating the milk to this temperature was designated 
as "pasteurization." In recent years pasteurization 
has been extensively employed, especially in large 
cities, and unquestionably with a favorable influence 
on infant mortality. 

Two methods are in use, a "holding" and a "flash" 
method. In the latter the milk is brought to a high 
temperature and allowed to cool ; in the former, it 'is 
held from fifteen to thirty minutes at a temperature 
which kills all organisms and spores. There seems to 
be little doubt that the "holding" method is preferable. 

Infants that are fed on a strict milk diet, and that 
pasteurized, seem susceptible to such diseases of altered 
metabolism as scurvy, rickets and purpura. The addi- 
tion of orange and other fresh fruit juices to the diet 
will aid in preventing such disturbances. 

THE NERVOUS CHILD 

Many a human being is born with an unstable ner- 
vous system. The neuroses are seldom of sudden onset 
but are usually the result of a long series of mental 
traumas, many of them occurring during infancy. 
These are recognizable to the careful diagnostician. 
As pointed out by McCready (Jour. A. M. A. 73: 1109, 
1919), parental fears are easily allayed when a trusted 
family physician or consultant, after examining a dis- 
tinctly hypoplastic nervous child, states that he can 
find nothing "organically wrong" and dismisses the 
patient with a tonic and a few vague directions about 
keeping the child out of school, getting him into the 
country, or giving him more milk to drink with the 
optimistic assurance that he is just a little nervous and 
anemic and will outgrow it after a while. "Equally 
dangerous," says McCready, "are the pessimistic prog- 
nostications of another variety of routinist, ignorant 
of the value of a proper combination of medical, 



656 THE NERVOUS CHILD 

hygienic and educational treatment. While some chil- 
dren are born nervous (hereditary causes), some 
acquire nervousness (disease, habits, etc.) and others 
have nervousness thrust on them (faulty training at 
home and at school). To counteract and to remove 
these causes in their various and combined phases is 
the duty (and the privilege) of the physician, and if 
he fails in its exercise he is derelict." 

Among the early signs and symptoms of such condi- 
tions are digestive disturbances, fretfulness, extreme 
sensitiveness to light and sound, convulsions, premature 
or late closing of fontanels, premature or late denti- 
tion, precocity or delay in the development of muscular 
control, in talking, undue sensitiveness of skin and 
mucous membranes, thumb sucking, head rocking, thigh 
friction, and manipulation of genitalia. In early child- 
hood they are constipation, perhaps alternating with 
diarrhea, anorexia, and perversities of appetite, aver- 
sion to particular articles of food, night terrors, muscu- 
lar twitchings, tics and muscular incoordination, stam- 
mering, lisping, idioglossia, enuresis, tremors of the 
fingers on extension, restlessness, irritability, perversity 
sometimes amounting to negativism, phobias, extreme 
timidity, fatigability, hyperemotivity, and many other 
abnormalities of life which will readily occur to the 
observant physician. If unchecked and uncorrected, 
aggravation of these symptoms occurs as puberty 
approaches. Negativism, stereotypy, and the typical 
"shut-in personality," psychasthenia and that short 
circuit of consciousness included in the term "neurosis" 
now develop. From the physical standpoint, the ner- 
vous child more than the child of stable nervous system, 
is likely to present the anomalies, such as marked 
cranial and facial asymmetry, ocular muscular imbal- 
ance, myopia, hyperopia, astigmatism, adenoids and 
enlarged tonsils, prognathism, irregular dentition, nevi, 
deviation of the nasal septum, phimosis, etc. He may 
show evidence of ductless glandular dysfunction, may 
be obese with short, stubby fingers, or slender with 
long bones and tapering fingers, may be sexually pre- 
cocious, or puberty may be delayed, may take on sud- 
den accesses of growth, or may fail to grow at the 
normal rate. 



SLEEP IN CHILDREN 657 



TREATMENT 



The treatment of the nervous child must begin with 
his environment. In his own household it is frequently 
difficult to modify the factors responsible for his ail- 
ment. As Strauch (Amer. Jour. Dis. Child 16: 165, 
1918) points out, children affected with minor ailments 
will in different environments and surrounded by dif- 
ferent persons present great variations in the clinical 
picture aside from the uiformity of the otherwise, of 
course, identical diseases, and act differently. Factors 
not lying within the nature of the pathologic processes 
themselves, but those of entirely extraneous characters, 
namely, the influences of the change of milieu, will 
call forth a change of the symptom complex in its non- 
obligatory, not organically caused, features ; the impres- 
sionable plastic psyche of the child being affected by 
the transformative circumstances as clay or wax is 
shaped under the hand of the modeling artist. 

If the child remains at home his entire life must be 
absolutely guided by the physician. Domestic arrange- 
ments must be modified as the physician directs. Rest 
is of great importance. The child should not be over- 
stimulated in its studies and should have sufficient 
sleep. 

SLEEP IN CHILDREN 

In a special study of sleep disturbances in children 
Strauch (Amer. Jour. Dis. Child. 17: 118, 1919) has 
classified those due to organic disease, extraneous 
causes, idiopathic types, stereotypias, motor irritation 
phenomena, dream types, somnambulism, pavor noc- 
turnus, hypnalgias, insomnia, environmental and sexual 
factors. 

Among organic factors responsible for troubled sleep 
is pain due to colic, distress or discomfort in gastro- 
intestinal disorders; even slight nutritional distur- 
bances cause babies to sleep poorly; likewise hunger 
as a result of a sudden diminution of the wonted 
amount of food, whilst in chronic underfeeding babies 
rather often will become accustomed to the small 
quantities ; itching and irritating or painful skin lesions, 
as eczema, urticaria, strophulus, intertrigo and fur- 
uncles, the latter especially if exposed to pressure 



658 SLEEP IN CHILDREN 

during sleep. Where sleep-disturbed nights precede 
the outbreak of urticaria it is probably due to the at 
first latent digestive disturbance that underlies both 
conditions. It is important to keep in mind that otitis 
media in the child — especially to be considered during 
epidemics of grip — may evidence itself by no other 
symptom than moderate fever and sleeplessness, result- 
ing from pain which is not localized by the infant, and 
thus easily overlooked. Fever itself may cause sleep- 
lessness. Respiratory obstructions and subsequent dis- 
comfort associated with adenoids, rhinitis or dyspnea, 
may cause awakening, starting with gasping for air 
and feeling of suffocation. Anemia and rickets -cause 
restless sleep as a nervous system. In this condition 
administration of phosphorus and cod liver oil may act 
almost as a specific. Likewise irritation of chorea, 
tetany and athetosis prevent sleep. 

Among extraneous causes of troubled sleep Strauch 
mentions deficient ventilation, lack of comfort, lack of 
quiet and darkness, faulty temperature of the room, 
with overheating or cooling of the body, exposure of 
feet in a cold room, lying wet. Too low temperature, 
insufficient covering will, especially in the morning 
hours, disturb sleep, as they act as awakening stimuli. 
The depth of sleep in infants depends on retention of 
warmth. Discomfort of the resting place comprises 
also the sleeping in the same bed of several persons. 
Whenever possible the child should .certainly sleep 
alone. 

Unfavorable crowded home conditions of the poor 
cause the younger children to be habitually deprived 
night after night of their full quota of sleep by the 
late retirement of the older persons of the family. 
Occasionally overburdening in school work, too much 
mental exertion, perverted distribution of the day 
hours, premature and untimely participation in social 
affairs and pleasures of the adult, especially dancing, 
abuse of alcohol, tea, coffee and tobacco, and even 
sexual stimuli, home work and home industry until 
late hours, will, by habitually curtailing the minimum 
sleep requirement, exert a detrimental effect on the 
young. Such children soon suffer in their general state 
of health ; the appetite decreases, they often have head- 

/ 



HABITS OF SLEEP 659 

ache, the mucous membranes lose their healthy hue; 
skin, muscles and panniculus adiposus become flabby 
and the youthful, frolicking nature with its love for 
work is replaced by inattention, fatigue and reduced 
efficiency in school work; finally, they become nervous 
and suffer from insomnia, establishing thus a vicious 
circle. 

Children often have the habit of falling asleep in a 
certain fashion ; as, for instance, with their playthings, 
a favorite toy animal or a doll, at their side, or with 
the corner of the bed clothes or one or more fingers in 
the mouth ; some will suck the finger only when falling 
asleep, though not at other times, this being apparently 
an agreeable sleep promoting stimulus. Other children 
will bite their nails, pull the bed cover over the face, 
will insist on a certain posture, lying on the stomach, 
or on the bent knees, or display some other preferred 
position and habit. The mothers know these little 
habits, perhaps being responsible for the development 
of such stereotypias, and are aware of the fact that the 
child will refuse to sleep if hindered in this peculiarity. 
If this habitual act is made impossible, falling asleep 
will be hindered. As Strauch indicates, some of these 
peculiarities are normal, but in many instances their 
similarity, degree and persistency may point to a neuro- 
pathic basis. 

Among motor irritation phenomena are jerking of 
the body, twitchings of leg or arm, rolling and tossing, 
grinding of the teeth, etc. During dreams the child 
may laugh, speak or cry, make sucking movements or 
even sit up in bed. With sufficient stimulation som- 
nambulism appears. Night terrors may be produced 
by disturbances of the nervous system or by horrible 
dreams associated with mental traumas received in the 
waking state. These may be associated with environ- 
mental factors; frequently parents tell children 
unwholesome morbid stories or intimidate the child 
with the bogy man, or by physical threat. In many 
such instances the child fearing to sleep alone will 
permanently ask for this or that or for an adult person 
to sit at the bedside, but then will distrustfully open 
their eyes time and again to see whether the person is 



660 TREATMENT OF SLEEP DISTURBANCES 

still present. Instinctive, indefinite fear of darkness 
may, especially in nervous children, prevent or other- 
wise disturb sleep. 

TREATMENT OF SLEEP DISTURBANCES 

A careful study of the child with the various causes 
of sleeplessness in mind will indicate the primary fac- 
tors in treatment. The external factors must be first 
controlled. Possible lack of comfort, hygiene and the 
other disturbing extraneous circumstances already men- 
tioned must be considered. The child's sleep should 
not be disturbed. Such bad habits as singing or rock- 
ing to sleep, feeding or drinking during the night, taking 
up the child or fondling it when it cries should be for- 
bidden. Especially difficult to treat are the fears 
affecting sleep. "The more certain it is that fear- 
affects interfere with sleep," says Strauch, "the more 
must we make efforts to free the victim of them by 
removing the psychic sources. It would be cruel not 
to alleviate dread. It may be necessary to keep the 
door open, so the child will know that a person is near 
by, or to keep a light burning low, to be turned down 
soon, of course, and extinguished finally, until in a few 
days, as a rule, the child will fall asleep alone in the 
dark room." The mother may calm the child by sug- 
gestion. It may be necessary completely to alter tem- 
porarily the child's psychic life. A system of rewards 
sometimes works wonders. 

Among physical measures, hydrotherapy has first 
place. A warm bath or warm pack and prompt return 
to a warm bed is very effective. In the treatment of 
disease conditions drugs should be administered symp- 
tomatically to secure the child the needed rest. In the 
chronic forms drugs are to be used most sparingly if 
at all. 

GENERAL TREATMENT OF THE NERVOUS CHILD 

No subject is receiving so much attention nowadays 
as questions of nutrition. Through school clinics, nutri- 
tion institutes and popular medical literature the proper 
feeding of children is being brought to the attention 
of the public. 

Equaling the importance of the prevention of over- 
fatigue is the regulation of the diet. Malnutrition 






PSYCHOGENIC DISTURBANCES 661 

affects not only those of narrow means but a large 
percentage of children from well-to-do homes are 
undernourished. The diet of the child, while perhaps 
not necessarily deficient in calories, is frequently com- 
posed mostly of carbohydrates, generating an evanes- 
cent energy, but failing to provide for tissue wear and 
tear, for growth and for storage for emergency. Such 
diet, also, is poor in vitamins and mineral salts; ner- 
vousness in children is often as much a deficiency 
disease as is scurvy or beriberi. 

Fresh air, bathing, regulated exercise and other good 
hygienic habits are important in the management of 
the nervous child. In many instances a trip to the 
country is followed by complete rehabilitation of the 
mental as well as of the physical constitution of the 
child. 

SPECIAL TREATMENT OF PSYCHOGENIC 
DISTURBANCES 

Most of these disturbances are readily treated by 
physical means, combined with a mild psychotherapy. 
It is necessary to remove the child from irritative 
factors or personalities. In many cases intentional 
neglect of the child's morbid manifestations reduces his 
sensitivity. 

In hysterical children, Strauch believes an alteration 
of the milieu must be radical and comprise not only a 
change of place, but in addition, also the absence of 
visitors, especially the separation from family members, 
the leaving at home of toys and books or other objects 
that have been in frequent use by the child and there- 
fore are closely connected and interwoven with his 
manifold associations and morbid complexes of ideas 
and emotions. 

The child may benefit greatly by meeting and playing 
with healthy and vigorous children ; this will divert 
his attention from his physical condition and the imita- 
tive instinct of the neuropath by being directed into 
other channels will be utilized in bringing the child 
back to normal habits and tendencies. Psychotherapy 
through simple verbal suggestions, particularly with the 
support of appropriate apparatuses, auxiliary manipu- 
lations, as massage, medication or other supplementary 
physical means, that impress themselves on the child's 



662 CONVULSIONS IN YOUNG CHILDREN 






mind as wonderful, mysterious or novel, and mask the 
psychic element of the treatment, has a strong influence 
toward recovery. In many instances the mere authori- 
tative word, the emphatic and positive assurance of 
cure, or, according to the individuality of the patient, 
gentle persuasion, the use of a placebo, or a system of 
rewards and punishment works an immediate cure, 
once the physician gains the child's friendship and 
confidence. 

The physician must have full confidence in his own 
ability to master the situation. If the first psychic 
blow falls very short of its goal and the prediction fails 
of early realization, the child's trust and faith in the 
curative force is considerably shaken and the proba- 
bilities of a cure by the same physician reduced. In 
cases of palsy it is often important to prove to the 
child that he can use his limbs much better than he 
supposed. "As a last resort, if not used, at the first," 
says Strauch, "a more powerful means, impressive 
through unpleasantness or even painfulness, will find 
its proper place; as for instance, the faradic current 
that even in tics, a usually obstinate affection, has 
proved to be of great curative value. Also cold baths, 
subcutaneous injections, bitter or disagreeable medi- 
cines and other measures of a disagreeable character 
come here into consideration." 

CONVULSIONS IN YOUNG CHILDREN 

Convulsions in infants are not a disease entity, but 
the demand for prompt treatment in every case has 
caused them to be considered as a group rather than 
in direct relation to the underlying cause. Needless 
to state, the condition usually means a hyperexcitabil- 
ity of the nervous system. This may be related to 
heredity, the parents being neurasthenic or neurotic; 
to lowered vitality; to errors in nutrition, most fre- 
quent in those artificially fed ; to chronic diseases such 
as rickets, syphilis, tuberculosis; or to some derange- 
ment of the glands of internal secretion. These rather 
general causes may be further exaggerated by the pres- 
ence of such exciting conditions as acute pain due to 
local infection; continued irritation, due to elongated 
prepuce ; to- this type also may be referred those cases 



CONVULSIONS IN YOUNG CHILDREN 663 

undergoing dentition. Because of the incoordination 
of the nervous system, infants seem especially predis- 
posed to convulsions ; but the fact that the convulsion 
may be a manifestation of any acute infectious dis- 
order, perhaps involving the nervous system, should 
not be overlooked. It is possible also that the convul- 
sions may be the first indication that the child is 
epileptic. 

The convulsions in young children may be divided 
into: (1) Those due to cerebral irritation (spas- 
mophilic) ; (2) those due to cerebral inflammation; (3) 
those due to acute cerebral congestion or to severe 
toxemia; (4) epileptic. 

1. The spasmophilic type is the most frequent, and 
may occur as a complication of any condition or dis- 
ease. Irritation due to the eruption of the teeth is a 
rare cause of convulsions, unless there is some other 
etiologic factor present. Worms do not frequently 
cause convulsions, unless sufficient alimentary distur- 
bance occurs simultaneously. 

Infants with this type of convulsions often have 
been artificially fed. Gastro-intestinal disturbances 
are the most frequent exciting cause of convulsions in 
children. If meningismus to the extent of convulsions 
occurs at the beginning of, or during, some acute dis- 
ease, it still may represent an irritation of the cerebrum 
from improper food or from improper care of the 
bowels, or from bad general hygiene, as bad air, insuf- 
ficient bathing,*skin irritations, or other general causes. 
In other words, convulsions rarely occur in the begin- 
ning of the exanthems in normal children. Probably 
a mild acidosis may be an underlying cause, especially 
if the child has been vomiting and has not had suffi- 
cient carbohydrate nutrition for a number of hours. 

Spasmophilic convulsions may be recognized by 
increase of all reflex irritability, restlessness and sleep- 
lessness. If a test is made, there will be found to be 
also an increase of electric irritability. 

Some spasmophilic children may have convulsions 
with very mild exciting causes, as an acute indigestion, 
or the beginning of one of the exanthems, or with the 
high fever of a tonsillitis or a bronchitis. Later in life 
these individuals are likely to have high fever with the 



664 TREATMENT OF INFANTILE CONVULSIONS 

least infection, and may be delirious with any high tem- 
perature. They are likely to be neurotic, high strung, 
irritable, and to display temper as children. A breast- 
fed baby is often immune against such spasmophilic 
attacks. This emphasizes the importance of the absorp- 
tion of toxins or irritants from the intestines as an 
exciting factor in spasmophilic convulsions. The most 
frequent age at which these convulsions occur is the age 
when an artificially fed infant is most likely to have 
gastro-intestinal disturbance, namely, from about the 
third month to about the end of the second year. Of 
course they may occur at any age thereafter. 

After a spasmophilic convulsion the patient does not 
sleep as he does after an epileptic convulsion, and the 
spasmophilic patient may have what has been termed 
spasmodic croup, or laryngospasm. This laryngeal 
tetanic condition may be sufficiently prolonged to cause 
death. 

True epileptic attacks may begin in infancy, and 
even in very young infants. The diagnosis may be 
made by the fact that spasmophilia rarely occurs in 
infants under 3 months of age, that contractions of 
the face and spasm of the larynx do not occur in 
epilepsy, and that increased electric excitability is a 
sign of spasmophilia. Also, as just stated, after a 
spasmophilic attack the patient generally does not 
sleep. Spasmophilic convulsions are likely to be multi- 
ple in number, while in the young child the epileptic 
convulsion is generally single, with longer or shorter 
periods of complete freedom from convulsions. 

TREATMENT 

The treatment of spasmophilic convulsions is purga- 
tion, unless the child has already had a severe diarrhea. 
Breast milk should be given if possible, if the patient 
is an infant; otherwise, the food should be starchy, as 
barley water or thin oatmeal gruel. Some alkali, as 
potassium citrate, is advisable, such as : 

Gm. or C.c. 

B Potassii citratis 21 gr. xxxvi 

Aquae menthae piperitae. 100| AS iv 

M. Sig. : A teaspoonful, in water, every three hours. 



TREATMENT OF INFANTILE CONVULSIONS 665 

Lime water should be given in teaspoonful doses five 
times a day. It is quite probable that the parathyroids 
are disturbed in all cases of spasmophilia, and calcium 
is a sedative to these glands as well as to the nervous 
system. 

If a mild sedative is deemed advisable, bromid may 
be given, best as sodium bromid, about 0.065 gm. 
(1 grain) for every year of the child's age, best given 
in plain water and repeated every two hours until the 
child is asleep; then the drug should be stopped alto- 
gether, if possible. In severer cases bromid is not 
successful, even in large doses, and chloral must be 
given, better by rectum, perhaps 0.13 gm. (2 grains) in 
an ounce of warm water and repeated in four hours, if 
needed. This dosage is for a child from 1 to 2 years 
of age. Cases of this type also show improvement 
under administration of phosphorated cod liver oil and 
the elimination of whey from the food, substituting 
albumin milk. 

The convulsions may be so severe and so frequent 
as to endanger the life of the patient; hence in such 
cases the treatment must be rapid and strenuous. 
Chloroform inhalations may be life-saving, and if 
convulsions recur as soon as the anesthesia is over 
(often primary anesthesia is all sufficient), it may be 
necessary to give opium in some form. A hypodermic 
injection of a small dose of morphin, depending on the 
age of the child, may be given. At the same time it 
should be remembered that morphin may act exces- 
sively in young children. 

The quieting effect of a tepid bath or of warm 
sponging must not be forgotten. If the child is 
exhausted it may be revived by stimulating the respira- 
tion by ice cold ablutions to the chest and abdomen. 

2. Convulsions due to inflammations of the meninges 
or to localized abscesses are much more frequent in 
children than in adults. First, the ears should be care- 
fully examined, as an abscess of the middle ear may 
not have been suspected, and may be the cause of the 
condition. Trouble in the ears or mastoid being elimi- 
nated, spinal puncture should be done and a careful 
examination made of the fluid withdrawn. 



666 TREATMENT OF INFANTILE CONVULSIONS 

The treatment of convulsions from some cerebral 
tangible cause is that of the disease found. Warm 
baths and bromids, and an ice cap to the head may 
alleviate the cerebral irritation. 

3. That young children often have one or more con- 
vulsions in the first stage of an acute infection is a fact, 
but such convulsions are not so frequent as many text- 
books would lead one to suppose. Such convulsions 
are often perhaps due to an exaggerated anaphylactic 
reaction caused by the toxins of the infecting germ. 
Or, in a patient who has inherited a neurotic tendency 
and is of spasmophilic type, sufficient cerebral con- 
gestion may be caused by a severe introductory chill 
to produce a convulsion. Many times, however, it is 
associated intestinal indigestion and the absorption of 
toxins from the intestine that cause the convulsion. 

The treatment is simply cool or tepid sponging to 
lower the temperature, which has generally developed 
by the time the child is seen, and a small dose of some 
antipyretic, as acetanilid, perhaps 0.015 gm. (one- 
fourth grain) to a child 4 years old, every two hours 
for four doses. 

Terminal convulsions in severe illness represent seri- 
ous toxemia, and can be combated only by treatment 
aimed at the general condition present, namely, to 
reduce very high temperature ; to stop excessive pain 
(often forgetting in a child; to relieve intestinal stasis; 
to brace a failing heart ; to prevent collapse, if possible ; 
to combat uremia, if present, etc. 

4. It should be remembered that true epilepsy may 
begin in infancy ; consequently, if a child has an occa- 
sional convulsion, and no acute inflammatory cause can 
be found, and especially if it is decided to be a true 
epileptic convulsion, every reflex irritant cause must be 
looked for and removed, if possible. There may be 
several factors causing epilepsy. A family history of 
epilepsy, chorea, alcoholism and mental disturbances, 
or instances in the family of mental defect will aid in 
the presumptive diagnosis that the child is beginning 
the disease of epilepsy. While the first sign of a true 
epilepsy may be a distinct convulsion, many times, 
especially in older children, the disease is preceded 
by a series of fainting spells or other petit mal attacks. 



ACIDOSIS IN CHILDREN 667 

A possible recurrent acidosis must be considered; 
hence the diet of a young child should be so modified as 
to supply plenty of carbohydrates, and it may be wise 
to give alkalies for a prolonged period. In increasing 
systemic alkalinity, however, it must be remembered 
that too much alkali may allow inflammations of the 
skin and cause bladder irritability. 

The mouth, nose, throat and genitalia must all be 
proved normal or else must be under suspicion as irri- 
tating causes of the convulsions. Headaches must, of 
course, be explained or seriously considered, if there 
is a history of such. Because there has been an injury, 
or because some slight depression on the skull is found, 
does not prove that such is the cause of the epileptic 
attack. A careful study of the part of the body in 
which the convulsion begins will often show the motor 
center that is in trouble, and may give the indication 
for operative interference. 

ACIDOSIS IN CHILDREN 

It has long been known that acidosis is a termination 
in diabetes mellitus, but that this serious condition may 
occur in any acute disease when there is prolonged 
vomiting, starvation, or even when the food is for a 
long time starch-free, is not always known or often 
guarded against. The vomiting after anesthesia, and 
the long continued administration of albumin water 
or other pure protein food after operations predispose 
to acidosis ; and collapse, shock and gastric disturbance 
are often due to this factor. While adults are not 
exempt from gastro-intestinal disturbances that may 
cause a condition of acidosis, children often suffer 
from the condition, and it has even been reported as 
occurring in epidemic form among young children. 

It seems unprofitable to discuss theories of the 
cause of this acute acidosis until more scientific data 
have been developed. Suffice it to say that an over- 
worked or disturbed liver seems to be unable to care 
for the fat offered it, and acetone products and result- 
ing acidosis are the consequence. Whether a toxin is 
formed in the intestine or is absorbed from some dis- 
tant infection, or from an infection of the nose, throat 
or lungs (as apparently so prominent in Metcalf's 



668 SYMPTOMS OF ACIDOSIS 

cases) which interferes with the liver activity, is not 
known. Many conditions might furnish such a toxin. 
There is probably always severe liver disturbance in 
the acidosis of diabetes mellitus. 

Acetone bodies are neutralized by the sodium, potas- 
sium or calcium of the blood and tissues. Hence the 
great loss of these alkaline elements if the acidosis 
persists, and the need for large amounts of alkaline 
salts to save the patient. 

SYMPTOMS 

The onset of symptoms in acidosis is usually sud- 
den, and generally the disease begins with vomiting. 
The most prominent symptoms are coated tongue, 
drowsiness, thirst, flushed face, prostration, diarrhea 
(about one third of the cases) and cerebral symptoms. 
The fever varies from a little above normal to 104, 
while in some of the most serious cases there is a 
low temperature; the pulse is rapid, and follows the 
temperature — the higher the temperature, the higher 
the pulse rate. With the prostration there is fre- 
quently a paleness about the mouth, quite noticeable; 
there is often dyspnea, and acidosis in any condition 
is a common cause of dyspnea or hyperpnea; the 
urine is scanty and generally clear, though sometimes 
cloudy; acetone is present and persists until after the 
urine becomes alkaline under the treatment. Diacetic 
acid may also be present ; it is a danger signal, and, if 
the patient recovers, it disappears from the urine before 
the acetone disappears. 

TESTS FOR ACETONE AND DIACETIC ACID 

Acetone. — To 5 c.c. of urine in a test tube add a 
small crystal of sodium nitroprussate and a few drops 
of strong acetic acid, and shake. Make alkaline with 
ammonium hydroxid. A purple color indicates acetone. 

Diacetic Acid. — To 5 c.c. of urine in a test tube add 
an excess of a 10 per cent, solution of ferric chlorid. 
A dark brownish red color indicates diacetic acid. 
Some drugs (salicylates) give this reaction, but it 
does not disappear on heating as it does when due to 
diacetic acid. 






TREATMENT OF ACIDOSIS 669 

TREATMENT 

The treatment, from start to finish, consists of the 
administration of alkalies, either sodium bicarbonate 
or potasium or sodium citrate. Most children can 
take and retain large doses of these drugs. If not 
retained, the alkali is given by the rectum. The doses 
must be large, to quickly combat the acidosis. The 
sooner the urine is rendered alkaline the better for 
the child. Four grams (60 grains) of sodium bicar- 
bonate every two hours is about the amount desired. 
Smaller amounts act much more slowly. Full doses 
will alkalinize the urine in from twenty-four to thirty- 
six hours. The more serious the symptoms, the more 
necessary it is to push the alkali. Sodium bicarbonate 
may be given as follows : 

Gm. or C.c. 

B Sodii bicarbonatis 201 3 ivss 

Aquae 200| AS vi 

M. Sig.: Two teaspoonfuls, in an equal amount of water, 
every thirty minutes. 

This dose is for any age, and is to be continued until 
the urine is alkaline, or at least until eight doses have 
been taken. The frequency may then be reduced to 
once in two hours, and then the dose may be given 
more or less frequently, depending on whether or not 
the urine is alkaline. If the intoxication is serious, the 
dose should be given every fifteen minutes 

If the medicine is not retained, peppermint water or 
wintergreen water may aid in its retention ; or it may be 
given by rectum, 2 grams (30 grains) in 2 ounces of 
water, every hour; or potassium or sodium citrate 
may be substituted: 

Gm. or C.c. 

I£ Potassii citratis 401 3 ix 

Aquae gaultheriae 200| fllS vi 

M. Sig. : Two teaspoonfuls, in an equal amount of water, 
every thirty minutes. 

This dose is for any age, and should be continued, 
increased or diminished in frequency as described for 
sodium bicarbonate, depending on the condition. 
Whatever the alkali used, it should be continued for 
several days in diminishing frequency of dosage even 
after the acute symptoms have subsided. 



670 AMMONIACAL DIAPERS 

Howland and Marriott suggest intravenous admin- 
istration when vomiting and diarrhea prevent admin- 
istration by mouth or rectum. Intravenous adminis- 
tration is the method of choice, especially when 
rapidity of action is desired ; and with acidosis, rapid- 
ity of action is always desired. The superior longitu- 
dinal sinus is available with infants, or the external 
jugular or femoral veins. With older children, a vein 
in the arm can often be employed. If facilities for 
the intravenous injection of alkali are not at hand, 
the injection may be made subcutaneously, with care 
that the bicarbonate has not been transformed into 
the carbonate, else severe sloughing of the tissues may 
result. A 4 per cent, solution is usually employed for 
intravenous use and a 2 per cent, solution for subcu- 
taneous use. The quantity to be injected depends on 
the size of the child, the severity of the symptoms 
and the effect produced, but the amount is always 
large. It must be given until the urine becomes alka- 
line; even in infants under 1 year, as much as 10 gm. 
in twenty-four hours may be required. With the cases 
of acetone body acidosis, with no sugar in the urine, 
and with a low sugar content of the blood, glucose 
by the rectum, subcutaneously or intravenously, seems 
clearly indicated in addition to the alkali. With all 
forms water is urgently required, especially with 
infants who are dehydrated as a result of vomiting 
and diarrhea. After one or two intravenous injections, 
the soda should be continued by mouth in doses of 1 to 
3 gm. every two or three hours until the urine is alkaline 
to litmus. In all cases of severe diarrhea, even though 
there are no evidences of acidosis, the authors deem 
it advisable to use sodium bicarbonate until the urine 
is alkaline. Its administration may prevent the devel- 
opment of acidosis. 

AMMONIACAL DIAPERS 

It may be noted that if the urine is made long alka- 
line, ammonium compounds may appear in the urine, 
and in infants who wear diapers this ammonia may 
combine with any alkali present in the diaper, such as 
"soap, lye, lime or stool," and cause severe irritation 






ACUTE DIARRHEA IN INFANTS 671 

of the buttocks. Hence in these cases the diapers must 
be thoroughly cleansed of all soap. 

DIET 

The best diet as soon as vomiting has ceased is 
probably barley water, oatmeal water, rice water, and 
soon afterward cereal gruels. 

When there is great "excitement" small doses of 
bromid or chloral should be given. 

ACUTE DIARRHEA IN INFANTS 

It is not our purpose to discuss this subject elabo- 
rately, but merely to recall a few therapeutic sugges- 
tions. 

1. With beginning abdominal disturbance we must 
consider, in infants, typhoid fever, dysentery, appen- 
dicitis, and infection of the kidneys, to say nothing 
of more serious conditions, as obstruction. During a 
diarrhea we must watch for symptoms of acidemia, 
and for meningeal complications. 

2. Eruptions that may be present may be due to 
food poisoning, other protein poisoning, or to drugs. 

3. We should seek for sources of focal infection, 
perhaps in the tonsils or in the ear, or perhaps a 
serious bronchitis or other lung condition. It should 
be recognized that streptococcic focal infections may 
cause diarrhea. 

4. The child should always be kept in the fresh air 
and outdoors, in the shade, if the weather is hot. If 
possible, a speedy removal to the seashore or to the 
country is advisable. This therapeutic measure should 
not wait until the child is hopelessly ill. 

5. Castor oil should be given. 

6. Food should be withheld. 

7. Plenty of water should be given. If the child 
cannot retain water in the stomach, after a colon 
wash, it may be retained in the colon. If water is con- 
tinually lost by the body, and cannot be retained in 
the stomach or colon, hypodermoclysis is advisable. 
Many a diarrheal patient dies from lack of water. 

8. In twenty-four hours (sooner if the patient is 
very weak) lactose, in from 3 to 5 per cent, solution, 
in water, should be given. 



672 ACUTE DIARRHEA IN INFANTS 

9. If the patient is acidotic, starch water and 
sodium bicarbonate should be given in small, frequent 
doses. Thin oatmeal gruel may be given. 

10. If there are frequent small stools, with consid- 
erable tenesmus and pain, the lower bowel should be 
washed out with 0.7 per cent, sodium chlorid solution 
once or twice daily. This should be done very gently. 
If it causes prostration, it should be stopped. 

11. While these treatments are going on, the stools 
should be examined for bacteria, to ascertain what 
pathogenic germs we must combat. 

12. If the stools are fetid, and especially if there is 
a tendency toward incomplete evacuation of the 
bowels, small doses of yeast may be given, in water, as 
one twentieth of an ordinary yeast cake, once a day. 

13. Phenyl salicylate, in 0.03 gm. doses for a child 
1 year old, may be given every three hours for a day 
or two, and then every six hours. Older children 
should receive a larger dose. 

14. If there is much irritation of the stomach or 
upper intestine, milk of bismuth may be given. It 
should not be given too long, and it is of no value 
given by the mouth for colitis. 

15. If the child is hot, it should be sponged with 
tepid water and kept cool. If it is cold, it should 
be kept warm with dry heat. Socalled antipyretics 
should not be given. A good working rule is to keep 
the abdomen warm, and the rest of the body cool. 

16. If stimulation is required, very small doses of 
atropin, or very small doses of strychnin, or both, may 
be given. 

17. If the child becomes constipated, and the bowel 
condition is troublesome, another dose of castor oil 
may be given. 

18. The mouth should be kept clean, but all mea- 
sures should be gentle. The usual antiseptic precau- 
tions should be used for all nose and mouth secretions, 
for the diapers, and for cleansing the clothing and bed 
linen. 

19. It is well to keep petrolatum spread over the 
anus and buttocks. This prevents irritation from the 
excretions, and is not conducive to germ growth. 



FOOD FOR CHILDREN 673 

20. As soon as advisable, the food should be 
increased by giving malted foods or malted gruels, and 
later by pasteurized milk, but the diet should be kept 
low until the abnormal temperature ceases and the 
stools are less frequent and contain no blood. 

21. A gradual return should be made to the regular 
milk or mixed diet of the child. 

22. Occasionally, when all measures seem to fail, 
if the child is a bottle-fed infant, a wet-nurse may be 
a life saver. If the child is a nursing child, the 
mother's milk may be at fault, and all possible sources 
of infection should be sought. 

FOOD FOR CHILDREN FROM TWO TO SEVEN 

It is possible to fulfil the requirements of a proper 
diet and still have a wide choice of foods for children 
from 2 to 7 years of age. It has been found that a 
healthy child from 2 to 4 years old requires daily from 
1,200 to 1,400 food units (calories) ; from 4 to 7 years 
of age the amount should be from 1,400 to 1,700 
calories. In general this discussion follows an outline 
prepared by Drs. L. Emmett Holt, Graham Lusk, L. E. 
Le Fetra and G. R. Psek for the New York City 
Health Department. 

Fats. — Regarding fats, it is said that both animal 
and vegetable fats are useful as foods, the animal fats 
being superior, however, and of these the most eco- 
nomical is said to be oleomargarin. 

Carbohydrates. — The carbohydrates include cereals, 
vegetables, breadstuffs, sugar and sweets. These are 
cheaper in bulk, and more expensive when purchased 
in special packages. When purchased in bulk, oat- 
meal, corn meal, hominy, samp and rice are most 
economical. Proprietary ready-to-serve foods are of 
higher cost and more difficult of digestion by young 
children, which more than offsets the ease of prepara- 
tion. 

Vegetables. — The value of vegetables depends not 
only on the amount of fat, carbohydrates and protein 
which they contain, but also on the richness in iron 
and other important salts, and on the amount of fiber, 
which aids proper action of the bowels. For these 
reasons they are indispensable to a proper diet, not- 



674 FOOD FOR CHILDREN 

withstanding their relatively high cost. Spinach, beet 
tops, chard and other "pot greens" are of particular 
value. For children of the ages under consideration 
no raw vegetables, such as radishes, tomatoes, cucum- 
bers, onions or celery, no green corn, peppers, egg 
plant or cabbage should be allowed. 

Breadstuffs. — Hot bread or rolls, griddle cakes and 
doughnuts should not be given to young children, but 
corn bread should be used for at least one meal a day. 
Bread and rolls should be stale or dried on the stove 
or in the oven till crisp. 

Sugars and Sweets. — No candy or chocolate should 
be given before a child is 5 years old, and then not 
more than one piece a day. Not more than one tea- 
spoonful of sugar should be given on a dish of cereal. 

Protein Foods. — One of the greatest difficulties in 
furnishing a proper diet at moderate cost is to supply 
the proteins in the amount needed. These foods as a 
class cost much more than either fats or carbohydrates. 
The cheapest and best protein for children is milk. 

Fish at certain seasons are cheap and useful. Vege- 
tables high in protein may largely replace meat in the 
diet, such as beans and peas, fresh or dried, which 
may be given as soups. Together with milk and bread, 
they may entirely replace meat. Wheat and oats con- 
tain most protein. Among the protein foods inter- 
dicted for children are sausage, pork, ham, liver and 
smoked salt or dried fish. 

Fruits. — Fresh fruits, though expensive except for 
the short time when they are in season, should be given 
freely. Berries, cherries, pineapple and plums should 
not be given, since they are not easily digested, and 
are usually expensive. Bananas should be thoroughly 
ripe, or else baked or boiled. The more extensive use 
of stewed dried fruits is urged. Fruit should be given 
with other foods and not between meals. 

Desserts. — Desserts permitted to young children are 
plain puddings made from rice, farina, cornstarch or 
stale bread; custard; junket, ice cream not oftener 
than twice a week and in small portions, bread with 
(corn) syrup or jelly; plain cookies, gingersnaps, 
sponge cake or lady ringers once daily with meals. 



FOOD FOR CHILDREN 675 

Pastries, pies and rich cakes, particularly those made 
with nuts and dried fruit, are forbidden. 

Drinks. — Milk, not less than a pint nor more than 
a quart daily, is cheaper and better than any other 
food of equal caloric value. It is indispensable for 
younger children. Cocoa, made with milk, may be 
substituted for milk in cold weather. Children should 
drink from two to four glasses of water daily. Tea, 
coffee, wine, cider and soda water are interdicted. 

Habits to Be Avoided. — Irregular meal times ; entire 
meals consisting of only one article of food ; imperfect 
chewing of food; rapid eating with much drinking 
during meals; feeding between regular meals. Coax- 
ing or forcing the child to eat without appetite, should 
never be done. 

Cooking. — Cereals should be cooked for not less 
than one hour, and most of them for three hours. A 
double boiler or a fireless cooker may be used. Green 
vegetables should be cooked with very little water; 
all vegetables should be thoroughly cooked. Potatoes 
should be boiled with the skins on and peeled after- 
ward, thus saving at least one sixth of the potato. 
Meats should be roasted, broiled or boiled; neither 
meat, chicken nor fish should be fried. Roasted or 
broiled meats should be eaten rare. Eggs should not 
be fried. Meat stews with potatoes and other vege- 
tables are to be recommended, provided they are thor- 
oughly cooked and the fat has been removed. Clear 
soups have almost no food value, but when vegetables, 
barley, noodles or rice are added they are useful foods. 
Thick soups, especially those made with peas and 
beans, with the addition of milk, are nutritious and 
cheap, and can largely replace meat and eggs in the 
diet. 

Sample Diets. — Following are sample diets furnish- 
ing sufficient quantities of food for healthy growth, 
but omitting meat on account of its high cost: 

SAMPLE DIET — TWO TO FOUR YEARS 

Breakfast, 7 a. m.: Cereal (oatmeal, hominy, rice or corn 
meal), 2 to 3 good tablespoonfuls with 1 even teaspoonful 
sugar and 2 ounces milk. Crisp toast or bread (stale), one 
or two slices with butter. Milk, 8 ounces, from cup. 



676 FOOD FOR CHILDREN 

Morning lunch, 10:30 a. m.: Milk, 6 ounces. Bread (stale), 
one slice. 

Dinner, 1:30 p. m.: One egg, or cup thick soup. Rice or 
macaroni, 2 tablespoon fuls, or one small baked potato. Fresh 
vegetable, 2 tablespoonfuls. Stewed fruit, 3 or 4 tablespoon- 
fuls. Bread, one or two slices, with butter. Water. 

Supper, 6 p. m.: Cereal, 2 or 3 good tablespoonfuls with 
sugar and 2 ounces milk. Milk, 6 ounces, from cup. Bread 
and butter, one slice. Custard, junket or plain pudding, 2 to 
4 tablespoonfuls. 

SAMPLE DIET FIVE TO SEVEN YEARS 

Breakfast, 7:30 a. m.: Cereal (as given for two to four 
years), 4 tablespoonfuls with 1 teaspoonful sugar and 2 ounces 
milk. Bread (stale white, graham or corn bread) or toast, 
with butter, two slices. Fruit, one fully ripe banana, peach, 
pear, or grapes, in season. Cocoa made with milk, one cup, 
or milk, 8 ounces. 

Dinner, 12:30 p. m.: Meat stew with vegetables; or soup 
made with milk and peas or beans; or fish; or egg. Potato, 
rice, samp or macaroni, with oil or butter. Fresh vegetable 
(spinach, chard, squash, carrots, turnips, string beans, boiled 
onions or celery), 3 tablespoonfuls. Bread and butter, one 
or two slices. Stewed dried fruit (apples, peaches, prunes, 
apricots), 3 or 4 tablespoonfuls. Ginger snaps or plain cake 
or jelly sandwich. Water. 

Supper, 6 p. m.: Cereal as at breakfast, with soup, or one 
egg. Bread (stale), two slices, with butter or peanut butter. 
Cup of cocoa made with milk. Plain pudding made with 
milk ; or stale bread with corn syrup. 

DIET IN GENERAL DURING THIS PERIOD 

The diets outlined are chosen with particular refer- 
ence to economy and healthfulness. When economy 
is not of chief importance the diet may be varied 
without injuring its healthfulness. 

Eggs when given should not be fried, but may be 
prepared in any of the other ways except hard boiled. 
Meat may be given once daily, preferably beefsteak, 
lamb chop, roast beef or lamb and white meat of 
chicken. Fish may be given, if fresh and prepared 
by boiling or broiling. 

Potatoes may be given baked or mashed and with 
the addition of cream. Among the vegetables aspara- 
gus tips, spinach, stewed celery, string beans, carrots, 
and cauliflower may be given (or, rather, should be 
given), at least once daily. 



INCONTINENCE OF URINE 677 

Among fruits oranges, baked apples and stewed 
prunes are best, but pears, peaches and grapes may be 
given when thoroughly ripe and fresh. The juice of 
berries also furnishes antiscorbutic substances. 

INCONTINENCE OF URINE IN CHILDREN 

This troublesome condition occurs mostly at night, 
and occurs in both boys and girls. More or less 
involuntary evacuation of the bladder at night is not 
considered abnormal in a babe or a young child, but 
when a child is over 3 years of age it must be consid- 
ered more or less pathologic. Among the most fre- 
quent causes are worms, elongated or adherent pre- 
puce or adherent clitoris, and the general restlessness 
and poor sleep caused by adenoid tissue in the pharynx 
interfering with breathing; less frequent causes are 
bladder irritation caused by an actual inflammation 
in the bladder, or by calculi. Of course simple or 
specific urethritis, vaginitis or any foreign matter in 
the vagina, diabetes mellitus, and diabetes insipidus 
may be causes. If none of these is present, it must 
be assumed that there is a congenital weakness of the 
sphincter muscle of the bladder, or that the urine is 
irritable and that there is a congenital hypersensitive- 
ness of the bladder, so that the least distention causes 
its contraction. The normal desire to urinate prob- 
ably comes as a rule from the posterior portion of the 
urethra slightly dilating and allowing urine to trickle 
into it. If this relaxation of the sphincter occurs 
abnormally, of course the reflex desire to urinate is 
abnormally frequent. 

If any of the foregoing reflex causes of nocturnal 
enuresis are present, proper treatment will stop the 
wetting of the bed. If none are present, recourse 
must be had to various treatments. Perhaps more 
valuable than medicinal treatment is a rearrangement 
of the general management of the child. Newlin 
(Arch. Fed., October, 1915) states that the method of 
management that has given him the best results con- 
sists in the simple procedure of anticipating the invol- 
untary emptying of the bladder. This is the usual 
accompaniment of any treatment, but, Newlin says, 



678 INCONTINENCE OF URINE 

when carried out systematically, can preclude the use 
of drugs absolutely; it gives far better results than 
when the chief reliance is placed on medicines with 
only perfunctory instructions as to the actual manage- 
ment of the child itself. This method of handling 
even obstinate cases of enuresis is rarely carried out 
systematically, but when it is so conducted gives almost 
invariably successful results. The chief obstacle 
encountered is the difficulty of impressing on the 
mother or nurse the fact that unless the instructions 
are absolutely faithfully followed the result is failure. 

The nurse is given a sheet of paper with the hours 
of the day and night placed in a vertical row at the 
left margin under the heading of the day of the 
week. If the enuresis occurs on an average of every 
two hours, she is instructed to put the child on the 
chamber every hour for the first twelve hours. If she 
finds the clothing wet at any such time the hour is 
noted on the chart. At night the child is lifted almost 
as frequently during the early hours, that is, up to 
11 o'clock or midnight; after that every second hour 
is usually all that is necessary for the first night. At 
the end of the first twenty-four hours she then either 
has a clear chart or one with several hours marked as 
indicating the time of the enuresis. On the second 
day she is guided by her chart of the previous day, 
and she may extend the length of time between the 
voluntary urinations, always, however, anticipating the 
hours marked as "wet" on the day before, placing the 
child on the chamber at least a half hour before the 
time indicated. 

The diet is important in the general management 
of such a child, and as soon as it is of such an age 
that milk is not necessary for its food it is better to 
restrict the amount of milk, as nearly two thirds of 
milk must be passed out by the urine. Of course 
coffee and tea should be eliminated from the diet of 
all children, especially of children suffering from this 
condition. The nearer the diet is vegetarian and 
cereal, the better for the patient, as vegetables keep 
more water in the intestines and pass more water out 
by the bowels and less by the urine than does a diet 
of more or less meat. All fluids should be restricted 
after 3 or 4 p. m. and the child should be awakened to 



INCONTINENCE OF URINE 679 

urinate when the parents go to bed. Preventing the 
child from lying on its back and raising the foot of the 
bed are old methods which are pretty generally known. 
The object is to prevent, if possible, the urine trickling 
into the back part of the urethra and starting the 
vesical spasm. 

While the child may be treated psychically, or men- 
tally impressed with different physical treatments, and 
perhaps in some way frightened into keeping up a 
nocturnal memory picture of the necessity of waking 
when the desire to urinate occurs, still, the patient 
should never be punished, as this is rarely of any 
value. 

Various electrical treatments have been tried, and 
probably none any more successfully than the faradic 
with an indifferent electrode over the spine and an 
active small electrode applied over the bladder, over 
the pubis and over the perineum, and the current made 
sufficiently strong to cause more or less contraction of 
the tissues. Theoretically this application of electricity 
may cause contraction and stimulation of the sphincter 
of the bladder, but most likely the greatest amount of 
good is done by the psychic effect on the child. Some- 
times the galvanic or constant current, with the large 
electrode on the spine being the anode and the more 
active smaller electrode being the cathode and the cur- 
rent allowed to make and break, is successful. 

Often the passing of sounds has seemed to be the 
cause of improvement. In other cases a cold perineal 
douche, or cold-water spongings applied to the peri- 
neum apparently cures the condition. 

Medication has not been very satisfactory. Prob- 
ably the most successful drug is atropin, either in 
the form of belladonna or atropin sulphate, and the 
amount given should be sufficient to cause some physi- 
ologic action. The dose to begin with would be 1/500 
grain of atropin sulphate to a child 5 years old, admin- 
istered at bedtime. This dose should be increased 
until some physiologic activity is evident. Frequently 
ergot or pituitary solution is a successful medication, 
especially when there is a tendency to polyuria or dia- 
betes insipidus. The ability of ergot to stimulate 
smooth muscle fiber is well understood, and that it is 



680 INCONTINENCE OF URINE 

more or less a sedative to the central nervous sys- 
tem is believed by many clinicians. The ergot is best 
administered as a thoroughly active fluidextract in 
doses of 10, 15, 20 or more drops, depending on the 
age of the child, and given directly after the evening 
meaL 

Though almost any treatment may at times be rap- 
idly successful, it must not be forgotten that many of 
these cases of nocturnal enuresis end abruptly without 
any special treatment, and the most inveterate cases 
frequently have the trouble cease at puberty, owing 
probably to a better development of all the muscular 
tissues of the genito-urinary tract. 



PHYSICAL THERAPY 



THE LOCAL APPLICATION OF DRY HOT AIR 

The general practitioner will usually not be able to 
apply the major elements of physiologic therapy to 
any great extent, because of the elaborateness of the 
plant required, but some of the minor elements can 
be perfectly utilized by the general practitioner, and 
most gratifying therapeutic results obtained. The 
local application of dry hot air is one of the most 
useful of them. 

There are on the market several forms of apparatus 
for its application, all of which will do good work. In 
order to be efficient an apparatus must be capable of 
producing 400 degrees Fahrenheit in fifteen minutes 
at the outside, and of maintaining this temperature 
indefinitely. In order to be useful to the general prac- 
titioner these machines must also be easily portable. 
They may be heated by gas, gasoline, alcohol, or elec- 
tricity. 

Preparation of the patient for the application is 
simple, consisting merely in covering the part of the 
body to be treated with three thicknesses of loose- 
meshed Turkish toweling, so as to secure intimate con- 
tact between wrapping and skin. If the perspiration 
which is induced as soon as the heat strikes the skin 
is allowed to remain on the skin during treatment, it 
will soon boil under the influence of the intense heat 
and blister the patient. These wrappings absorb it as 
soon as it is formed, the heat immediately vaporizes 
it and it rapidly diffuses itself out of the wrapping. 

Directions for the general operation of the machines 
are furnished by the manufacturers. Complete trea- 
tises on thermotherapy can be obtained by those who 
take more than a passing interest in it. 

The physiologic effect of the dry hot air application 
is produced in two ways : first, by thermic irritation of 
the numerous nerve-endings in the skin and, second, 
by the actual raising of the temperature of those por- 
tions of the body in immediate contact with the heat. 

Irritation of the nerve-endings of the skin results, by 
reflex action, in (1) marked dilatation of the capillary 



682 APPLICATION OF DRY HOT AIR 

areas, hence greatly increased blood supply; (2) enor- 
mously increased function of the sweat glands, hence 
increased local elimination, and (3) acceleration 
of the cell nutrition and 4 function through reflex stim- 
ulation of the spinal centers. The raising of the tem- 
perature, en masse, results in acceleration of the 
chemical reactions constituting the cell metabolism of 
the part. It will be observed that the combination of 
these influences results in increased physiologic resis- 
tance of the tissues affected and acceleration of the 
process of repair of damaged tissue elements. 

The sphere of action of this application, then, is 
in the treatment of pathologic conditions which are 
strictly local in character, and which can be happily 
influenced by increasing the local physiologic cell resis- 
tance and the local nutritional, absorptive, and elimi- 
native functions. Such conditions obtain in many dis- 
eases encountered by the general practitioner, but it 
will suffice to mention two which illustrate the differ- 
ent types of cases in which the local dry hot air appli- 
cation is most useful. These are sprains and most 
cases of true rheumatism in which but one or two 
joints are involved. . 

SPRAINS 

In an uncomplicated sprain the lesion consists simply 
of an injury of the soft tissues about the affected 
joint, accompanied by severe pain probably due to con- 
gestive irritation of lacerated nerve fibers. The thera- 
peutic indications are (1) to relieve pain, (2) so to 
influence the trophic functions as to secure the quickest 
possible repair, and (3) to promote absorption of the 
exudate. 

If a sprain is put under treatment by this agent 
within three or four hours after the injury has been 
sustained, the pain will be relieved within half an hour, 
and all traces of the trouble will usually have dis- 
appeared within forty-eight hours. If the case is 
three or four days old, however, and exudate is pres- 
ent to any great extent, complete removal of the dis- 
ability may require from two to three weeks; but the 
pain is usually susceptible of the same immediate relief 
as in early cases. 



HYDROTHERAPY 683 

Among other conditions in which the local applica- 
tion of hot air is more or less useful are pleurisy, 
acute gout, synovitis, fibrous ankylosis, some cases of 
neuritis, varicose ulcers, and sluggish healing processes 
not due to malignant, tuberculous or syphilitic infec- 
tion. 

HYDROTHERAPY 

The role of baths and hot and cold applications in 
the treatment of disease has frequently been mentioned 
in the preceding articles. 

Hydrotherapeutic measures of various kinds are 
valuable in the treatment of all mental disturbances. 
Many water treatments are very soothing, and every 
sanatorium and asylum for the care of the insane 
should be equipped for giving hydrotherapeutic treat- 
ment. 

WATER BY MOUTH 

Water by mouth should be urged in definite quanti- 
ties fixed by the physician. It is an excellent diuretic. 
When urging water, under various conditions, the 
amount of urine passed in twenty-four hours and the 
specific gravity of the twenty-four hours' output should 
be known, as well as the less frequently omitted exam- 
inations for albumin and sugar. If the urine were 
more frequently examined during simple acute proc- 
esses the profession would be surprised at the fre- 
quency with which disturbances of the kidney func- 
tions are found. Too frequently, when an insufficient 
amount of urine is passed, more or less irritant diu- 
retics are given when simply an increased amount of 
water is needed. 

A caution should be noted here, that with real 
nephritis, or with an insufficiency of the heart, or a 
failure of the circulation, or when there is edema, 
large amounts of water should not be drunk. On the 
other hand, in conditions in which water should be 
administered both as a diuretic and to dilute all the 
excretions, it is not sufficient for the physician to direct 
a patient to "drink plenty of water," but he should 
specify the amount of water he wishes taken during 
the twenty-four hours. 



684 CONTINUOUS BATHS 

Especially is it necessary, during acute infective 
processes in children, to urge their drinking plenty of 
water, perhaps as lemonade, orangeade, or barley 
water ; but water in some form should be freely given. 

CABINET BATHS 

Cabinet baths are used in various toxemias to 
encourage elimination through the skin. Where there 
is marked physical deterioration, advanced circulatory 
or cardiorenal disease, they should be given with 
caution. 

This treatment should be given by trained atten- 
dants who can interpret physical symptoms. Medicinal 
stimulants should be close at hand, an ice cap applied 
to the head, and water given freely during the time of 
sweating. Perspiration usually becomes profuse at the 
expiration of about ten minutes, and the patients 
should immediately receive a cold shower in order to 
avoid catching cold. Cabinets should be well pro- 
tected, all heat pipes or frame work properly protected, 
and doors to the cabinets should be such that they can 
be opened quickly. The neck should be well covered, 
and a large towel should enclose the patient's lower 
body in order that the procedure may be done as 
modestly as possible. 

CONTINUOUS BATHS 

The continuous bath is usually a warm bath, which 
does not drop below 88 or exceed 100 F. It can be 
used in cases of depression as well as in marked 
excitement. Aside from the therapeutic effect it seems 
to have a moral influence over certain incorrigible 
patients. Incorrigibility itself is not an indication. 
The bath may be administered in several forms; tubs 
may have separate regulators, but preferably, one cen- 
tral stand should be the control. Patients may be 
given the freedom of the bath or they may be 
restrained, depending on the nature of the case as well 
as on the therapeutic result desired. A bath of short 
duration at frequent intervals has more advantages 
than a prolonged bath of days or weeks. 

The contraindications are, first, the tub baths should 
not be prescribed for cases with marked physical 
deterioration, or in wasting or advanced diseases or in 



SITZ BATHS 685 

skin diseases ; second, cabinet sweats are contraindi- 
cated in cases in which there is great excitement as 
well as serious physical disease. 

HYDROTHERAPY IN UROLOGY 

Martin (Jour. A. M. A., Jan. 9, 1915, p. 102) dis- 
cussed various hydrotherapeutic measures of value in 
urology. 

Frequent applications of short fomentations, either 
hot or cold, cold compresses, or hot or cold immer- 
sions, he finds constitute a valuable adjunct to any 
treatment in combating infections. Patients with acute 
specific urethritis experience relief and more speedy 
cure by immersing the penis in alternate hot and cold 
water several times a day, as an adjunct to regular 
treatment. 

THE SITZ BATH 

A hydriatic measure frequently prescribed by urolo- 
gists is the sitz. If the proper technic is fol- 
lowed it has a marked analgesic effect. Patients, 
when taking their own treatment, find the relief so 
gratifying that they may remain in it too long, result- 
ing in an atonic reaction that is more or less debilitat- 
ing. When used for its analgesic properties for calculus 
c lie this relaxed effect is desirable, but not when 
combating chronic congestions or infections. "The best 
effect is obtained from a short hot sitz, from 115 to 
120 F., for five to eight minutes, followed by a short 
cold dip or affusion, the reaction of which prolongs 
the primary tonic effect of the heat, by producing a 
tonic dilatation of the peripheral vessels, and a more 
active circulation. A hot sitz should always be fol- 
lowed by a cold sitz when treating chronic infections." 
In private homes, Martin suggests the effect can be 
obtained in a measure by gradually cooling the water 
or dashing cold water on the parts from a bucket. In 
cases of chronic infections, the advantage of such a 
bath is augmented by preceding it with alternate hot 
and cold sprays and ascending perineal douches. 

Martin emphasizes the value of the prolonged cold 
sitz. He noted that gynecologists use it effectively in 
the palliative treatment of uterine fibroid, with chronic 
congestion accompanied by menorrhagia. "They have 



686 SITZ BATHS 

demonstrated," he says, "by experience that the reac- 
tion following cold sitz baths increases the circulation 
in the uterus, which aggravates the menorrhagia, but 
prolonged (from twenty to thirty minutes at 60 to 
70 F.), produces continued contraction of the pelvic 
and abdominal viscera, with a relief of congestion fol- 
lowing. The prolonged active stimulation of the vaso- 
motors exhausts them, thus losing their power to 
react, so that the primary effect of the cold is con- 
tinued after the bath. Much of the benefit derived 
by the patient from this measure is due to the contrac- 
tion and tone to relaxed intestinal viscera, which 
noticeably increases their activity and thus stimulates 
nutrition and intestinal elimination." This measure 
has proved valuable in the palliative treatment of pros- 
tatic hypertrophies with congestion, malignant growths 
with hemorrhages, atonic dilated bladders (especially 
following prostatectomies) and in sexual debility. 

Care should be exercised at the start. Weak and 
debilitated patients should not be given the prolonged 
cold baths until their ability to ^eact is established. 
This is accomplished by gradually reducing the tem- 
perature and extending the time from day to day.- 
Reaction can be facilitated by a simultaneous hot foot 
bath, and especially by vigorous friction to parts 
immersed. Chilling is prevented by protection of the 
shoulders with flannel. The cold sitz should be pre- 
ceded by a hot rectal irrigation, and followed by a 
spray. It is positively contraindicated in all cases of 
vesical tenesmus. 

The neutral sitz, taken with water at 92 to 95 F. 
for from fifteen to thirty minutes, Martin finds valu- 
able, because of its soothing and sedative effect in all 
irritable conditions accompanied by priapisms or eroto- 
mania. 

Another useful measure, which can be utilized by 
patients at home, is the heating .pelvic pack. A piece 
of linen, flannel and mackintosh, shaped and applied 
like an infant's napkin, is used as a heating compress 
to any other part by wringing the linen out of ice water 
and applying next to the skin, covered by flannel and 
mackintosh. Its action produces dilatation of super- 



GRUELS AND STARCHY DRINKS 687 

ficial vessels, with relief of internal congestions. It 
possesses a decided value in the relief of pain and for 
activating the circulation in cases of cystitis, prosta- 
titis, epididymitis, and similar complaints. It is a valu- 
able after-treatment following a sitz or hot fomenta- 
tion, and is best employed at night. 

General measures, such as packs and electric light 
baths, and tonic measures, as hot and cold applications 
to the spine, salt glows and general hot and cold 
sprays, are valuable in stimulating general vital tone. 
With their proper use, weak, anemic and debilitated 
patients, who may be suffering from some condition 
demanding radical treatment, and unable to stand it, 
may often be built up. Combinations of these appli- 
cations, graduated as the patient's ability to react indi- 
cates, are effective in many cases of acute and chronic 
infections. 

The routine use of the hip and leg pack followed 
by cold-mitten friction after surgical procedures is 
sometimes a valuable measure to abort shock and pul- 
monary congestions. These are conveniently given by 
the use of the electric thermaphore pack, which is 
placed on the bed and the current turned on before 
the patient returns from the operating room. The 
patient is thus put at once in a warm pack, which is 
folded around the legs and hips and heated by the 
electric current for ten or twelve minutes. A cold- 
mitten rub completes the treatment. 

GRUELS AND STARCHY DRINKS 

The food value of a starchy drink during certain 
illnesses is considerable ; also, many thin cereal liquids 
are very soothing to patients with gastro-intestinal 
disturbances. With seriously ill patients a happy 
arrangement of a mixed diet of some milk, some beef 
juice, and some thin, digestible, well-cooked starch 
makes the most appropriate food. 

The following suggestions of the way such nutri- 
tious drinks should be prepared are from "Practical 
Dietetics," by Alida F. Pattee. For convenience, an 
approximate estimate of the calorific, value has been 
added to each receipt. 



688 GRUELS AND STARCHY DRINKS 



FLOUR GRUEL 

Milk 1 cup 

Flour y 2 tablespoonful 

Salt 1 speck 

Raisins 1 dozen 

Scald the milk, mix the flour with a little cold milk 
and stir into the scalding- milk. Cook in a double 
boiler for one-half hour or on back of stove in sauce- 
pan. Stone and quarter the raisins, then add water 
enough to cover; cook slowly until the water has all 
boiled away; add to gruel just before serving, or eat 
with the raisins as desired. If there is much diarrhea 
the raisins should be left out. 

Energy value approximately 150 calories. 

BARLEY GRUEL 

Barley flour 2 tablespoonfuls 

Milk, scalded 1 quart 

Salt. 

Blend the barley flour with a little cold milk and 
stir into the scalding milk. Cook in a double boiler 
two hours, salt to taste, and add sugar if desired; 
strain. 

Energy value approximately 650 calories. 

BARLEY GRUEL WITH BROTH 

Beef broth 2 cups 

Barley flour .2 tablespoonfuls 

Cold water 2 tablespoonfuls 

Salt 1 saltspoonful 

Mix barley flour and salt with the cold water, to 
form a smooth paste. Add gradually to the boiling 
stock and boil one-half hour. Strain and serve very 
hot. 

ARROWROOT GRUEL 

Arrowroot 2 teaspoonfuls 

Cold water 2 tablespoonfuls 

Boiling water or milk 1 cup 

Sugar, lemon juice, wine or brandy as required. 

Blend the arrowroot and cold water to a smooth 
paste, add boiling water or milk and cook in a double 
boiler for two hours. Add salt, strain, and serve hot. 



GRUELS AND STARCHY DRINKS 689 

Both the barley and arrowroot may be administered 
in diarrhea. 
Energy value approximately 150 calories. 

INDIAN MEAL GRUEL 

Indian meal 1 tablespoonful 

Flour x /z tablespoonful 

Salt X A teaspoonf ul 

Cold water 2 tablespoonfuls 

Boiling water \ x / z cups 

Milk Or cream. 

Blend the meal, flour and salt with the cold water to 
make a smooth paste and stir into the boiling water. 
Boil on back of stove one and one-half hours, dilute 
with milk or cream, strain. 

Energy value approximately 250 calories. 

RICE GRUEL 

Rice flour 1 tablespoonful 

Cold water 2 tablespoonfuls 

Boiling water 1 quart 

Salt. 

Mix the rice flour with a little cold water, to form a 
smooth paste, add the boiling water, and cook in a 
double boiler until transparent and thoroughly cooked. 
Add salt to taste, sweeten, and add milk if desired; 
strain. 

Energy value approximately 40 calories. 

OATMEAL GRUEL 

Coarse meal % cup 

Salt Yz teaspoonful 

Boiling water Wz cups 

Milk or cream. 

Add oatmeal and salt to the boiling water, cook 
four or five hours in a double boiler, adding more 
water if necessary. Strain, and dilute with hot milk 
to make it of the right consistency. Heat and serve. 
Sugar may be added if desired. 

Energy value approximately 150 calories a cup. 



690 GRUELS AND STARCHY DRINKS 

FARINA GRUEL 

Farina 1 tablespoonf ul 

Cold water 1 tablespoonf ul 

Boiling water 1 cup 

Scalded milk 1 cup 

Salt. 

Mix the farina with the cold water, add to the boil- 
ing water and boil thirty minutes. Add the scalded 
milk, taste and season properly. A little sugar may 
be added if desired, or an egg may be beaten and the 
gruel added to it. 

Energy value approximately 150 calories. 

BROWNED FLOUR GRUEL 

Tie one- fourth pound of wheat flour into a thick 
cloth and boil it in a quart of water for three hours. 
Remove the cloth and expose the flour to the air, or 
heat it until it is hard. Grate from it when wanted a 
tablespoonful, put into half pint of new milk, and stir 
over the fire until it comes to a boil, add a pinch of 
salt and a tablespoonful of cold water, and serve. This 
gruel is excellent for children with simple diarrhea. 

BARLEY WATER 

Pearl barley Wz tablespoonfuls 

Cold water 1 quart 

Salt enough 

Wash the barley, add cold water, and let it soak 
several hours; drain and add the fresh cold water, 
boiling gently (over direct heat for two hours) down 
to one pint, adding water from time to time; salt to 
taste, and strain through muslin. Cream or milk may 
be added, or lemon juice and sugar. This makes a 
demulcent drink, slightly constipating. 

RICE WATER 

Rice 2 tablespoonfuls 

Cold water 1 pint 

Boiling water or hot milk enough 

Salt enough 

The carefully washed and cleaned rice should be 
added to the cold water and cooked an hour, or until 
the rice is tender. Strain, and dilute with the boiling 
water or hot milk to the desired consistency, and 



ALBUMINOUS DRINKS 691 

season with salt. Sugar or cinnamon may be added if 
desired or advisable. 

OATMEAL WATER 

Oatmeal 1 tablespoonful 

Cold water 1 tablespoonful 

Salt a little 

Boiling water 1 quart 

Mix the oatmeal and cold water, add the salt, and 
stir into the boiling water. Boil three hours, adding 
water as it boils away. Strain through a fine sieve or 
cheesecloth, season, and serve cold. 

TOAST WATER 

Stale bread, toasted 1 cup 

Boiling water 1 cup 

Salt enough 

Dry in an oven thin inch squares of the bread until 
crisp and brown. Take a cupful of this toast broken 
into crumbs, add water, and let it stand one hour. 
Strain through cheesecloth, season, and serve hot or 
cold. If desirable, milk or cream and sugar may be 
added. 

ALBUMINOUS DRINKS 

EGG BROTH 

Yolk of egg 1 

Sugar 1 tablespoonful 

Salt 1 speck 

Hot milk 1 cup 

After beating the egg, add the sugar and salt, and 
then pour on the hot milk. 

Energy value approximately 230 calories. 

ALBUMINIZED MILK 

Milk *. 1 CUp 

White of egg ■'• 1 

Salt. 
Flavoring. 

Place the milk and egg in a covered glass fruit jar, 
shake until thoroughly blended, salt and flavor as 
desired. Strain and serve immediately. 

Energy value approximately 150 calories. 



692 PREPARATION OF BRAN BREAD 



BRAN BREAD 

Wheat flour 2 cups 

Graham flour 2 cups 

Bran flour 2 cups 

Salt 1 teaspoonf ul 

Sugar Va cup 

Baking powder 1 teaspoonf ui 

Milk 2 cups 

Molasses 1 cup 

Egg # 1 

Soda 2 teaspoonf uls 

Hot water % cup 

Raisins 1 cup 

Thoroughly mix the foregoing liquid and solid in- 
gredients, and bake in a moderate oven for one hour. 
This makes two loaves. 



MISCELLANEOUS 



ANESTHESIA 

ESSENTIALS OF SAFE ANESTHESIA 

Before commencing the administration of the anes- 
thetic, the anesthetist should give careful attention (1) 
to the operating room; (2) to the emergency table; 
(3) to the patient. 

The operating-room must be warm, and the operat- 
ing table as comfortable as possible for the patient. 
There must be plenty of blankets. The legs and arms, 
a low pillow for the patient's head, and a pillow for 
the back, should all be arranged to be as comfortable 
and warm as possible without, of course, interfering 
with the exigencies of the particular operation. It is 
advisable to have a strong, well-working faradic bat- 
tery, an oxygen tank (it should be remembered that 
Professor Henderson thinks too much oxygen in ether 
shock is inadvisable, and even advises carbon dioxid 
gas), transfusion apparatus, and warm, aseptic physio- 
logic saline solution. 

The articles on the emergency table should comprise : 

1. Chloroform. 

2. Ether. 

3. Petrolatum. 

4. Boric acid eye-drops (1 per cent.). 

5. Tongue forceps. 

6. Long forceps for swabbing, and properly made 
gauze or cotton pledgets (no ravelings), or pieces of 
sponge. 

7. A mouth gag, or cork, or a piece of rubber. 

8. A large needle threaded with strong silk. 

9. A pus basin. 

10. Towels. 

11. Two hypodermic syringes. 

12. Atropin sulphate tablets — each 1/200 of a grain. 
(The amount is small, but the dose may be repeated, 
if needed.) 



694 ESSENTIALS OF ANESTHESIA 

13. Strychnin sulphate tablets — each 1/40 of a 
grain. (The amount is small, but the dose may be 
repeated, if needed.) 

14. Ampoules of saturated solution of camphor in 
sterile olive oil. 

15. Ampoules of aseptic ergot. 

16. Epinephrin and pituitary solution in aseptic 
ampoules— 1:10,000. 

The Patient: 

1. A twenty-four hours specimen of urine should, 
if possible, have been examined; certainly a single 
specimen should have been examined. 

2. The condition of the heart and arteries should 
have been examined and the best anesthetic selected. 

3. The patient should have received* no solid food 
for a number of hours before the operation. If the 
operation is done early in the morning, it is best, three 
hours before the operation, to give either a cup of hot 
bouillon or a cup of black coffee. 

4. The bowels should have been properly moved, 
generally by the aid of some cathartic, and often an 
enema is advisable at least an hour before the opera- 
tion. 

5. The urine should have been passed immediately 
before the administration of ether is begun. 

6. False teeth should be removed. The nose, throat, 
mouth and teeth should be cleansed with an antiseptic 
wash. Hairpins should be removed, if the patient is a 
female,, and the hair should be properly bound up 
under a cap ; it is better that this cap is not made air 
tight as the head is likely to become very moist with 
perspiration, if the cap is impervious. 

7. The face should be anointed with petrolatum as 
the vapor of ether is irritant to the skin. 

8. The rate of the pulse and the feel of the radial 
and temporal arteries should be noted before the anes- 
thetic is begun. 

DUTIES OF THE ANESTHETIST 

The anesthetist should be someone who is especially 
fitted for this work. He should devote his entire 
attention to the anesthesia, and his attention should 



DUTIES OF THE ANESTHETIST 695 

not be diverted from his own work to the operation, 
or for any other purpose. He should make himself 
aware of the condition of the heart by holding the 
index finger of one hand over the temporal artery 
where it passes over the zygomatic process in front of 
the ear. He can be aware of the condition of the 
respiration either by the rise and fall of the chest or 
by noting the exhalation of the air through the mask. 

Next to the pulse and respiration, the pupil of the 
eye is the most important index of the condition of the 
patient. Sudden dilatation of the pupil, especially if 
accompained by hiccough, is a grave symptom, and 
should indicate the immediate suspension of the anes- 
thesia and the withdrawal of the ether. 

In order to determine when anesthesia is complete 
many separate the eyelids and touch the conjunctiva 
with the tip of the finger. This is a dangerous prac- 
tice and should not be followed, as the eye may be 
injured or infected. 

A most useful test for determining complete anes- 
thesia is raising the arm. If this falls without any 
muscular contraction, the anesthesia is complete. This 
condition may be present shortly after the administra- 
tion of the ether is commenced, the socalled primary 
anesthesia, which may be followed by a brief return of 
muscular activity. The continued administration of 
the ether will soon produce complete anesthesia. If 
the operation is an abdominal one, a little ether poured 
on the abdomen will soon show, by reflex action from 
the cold, whether the patient is thoroughly anesthetized 
or not. Also, manipulations of any kind in the region 
to be operated on will often awaken an incompletely 
anesthetized patient when other signs have apparently 
pointed to complete anesthesia. 

The patient should be kept as lightly under the 
influence of the anesthetic as is possible. Very deep 
anesthesia should be avoided. The anesthesia should be 
as brief as possible, but this, of course, rests with the 
operator. As soon as an operation is completed, the 
ether should be withdrawn. Often this can be done 
before the final stitches are inserted and the dressing 
applied. If the patient has not been too deeply anes- 
thetized, he should begin to regain consciousness 
shortly after the withdrawal of the ether. 



696 NAUSEA IN ANESTHESIA 

NAUSEA AND VOMITING 

One oi the most troublesome of the sequelae of the 
administration of ether is nausea and vomiting. The 
exact cause of this has not been determined definitely. 
Some have believed that it was due to the irritation of 
the mucous membrane of the stomach from the ether 
swallowed, but this is probably not so, at least in all 
cases. Various methods have been proposed to com- 
bat this disagreeable symptom. All are more or less 
successful. If morphin has been administered before 
the operation, nausea apparently does not occur as soon 
as when it has not been administered. It is often 
advisable to give an injection of morphin and atropin 
directly after the patient comes out of the anesthesia, 
that he may not suffer pain and shock from such pain 
Such an injection prevents the nausea, at least for a 
number of hours. Hot water, administered frequently 
in teaspoonful doses, is often a successful, simple 
treatment. If mucus and gas are eructated, or actually 
vomited, large draughts of hot water should be taken., 
that the stomach may be thoroughly washed out by 
vomiting, or by the liquid passing the irritant onward 
into the bowel. Some surgeons believe in washing 
out the stomach. This is not often advisable, but is 
indicated if bile is regurgitated, or if blood is extrav- 
asated into the stomach. Oxygen inhalations have 
been suggested. Pure olive oil, in ounce doses, has also 
been found useful in this condition. Of course, the oil 
would soothe the stomach, and would be especially 
sedative, if there was an increased amount of hydro- 
chloric acid present in the stomach. 

BLADDER AND KIDNEYS 

A not infrequent sequence of the administration of 
ether is an irritable bladder and more or less local 
congestion. This is shown by a slight albuminuria and 
by a diminished amount of urine. Such an irritation 
may be caused not only by the ether itself, but also by 
the profuse sweating and the small amount of fluid 
which has been ingested, causing the urine to become 
very concentrated and therefore irritant. To avoid 
such irritation, it is often good treatment, before 
operation, to inject a pint of hot water, with or with- 



SALINES IN ANESTHESIA 697 

out salt (a physiologic saline solution), into the colon. 
Such liquid is rapidly absorbed and dilutes the urine 
and all the secretions and increases the excretion 
of urine. Such frequent irritation of the kidneys 
makes it inadvisable, unless there is positive necessity 
to administer ether a second time to the same person 
within so short a period as a week. In fact, it has been 
shown that serious kidney congestion can occur follow- 
ing an ether or chloroform narcosis several weeks 
subsequent to an anesthesia. This tendency to irritate 
the kidneys makes ether an anesthetic generally contra- 
indicated when there is kidney disturbance, especially 
if there is any acute inflammation present. 

To hasten the elimination of ether from the system, 
plenty of fresh air should be allowed in the room, pro- 
vided it is sufficiently warm. The patient, under any 
circumstances, must be surrounded with hot-water bot- 
tles and blankets so that he may not lose too much heat, 
or better, may even acquire heat, during the shocked 
condition subsequent to anesthesia. 

SALINES 

If much blood has been lost and the patient is in a 
condition of collapse, besides administering physio- 
logic saline solution by the rectum, intravenous or 
subcutaneous transfusions of saline solutions are often 
advisable. Raising the foot of the bed should also not 
be forgotten in this condition. It may be here paren- 
thetically stated that when the Trendelenburg position 
has been long used in an operation the return of the 
patient to a level should be brought about gradually, 
lest anemia of the brain be caused. 

LUNG COMPLICATIONS 

Another untoward effect is sometimes the develop- 
ment of a pneumonia. It has been proved that either 
ether, chloroform, or alcohol diminishes the resistance 
of the cells to bacteria. Pneumonia is more apt to 
supervene when the narcosis has been deep and pro- 
tracted. Many believe that it is also encouraged by the 
inhalation of cold air with the ether, and it also 
undoubtedly happens that the development of pneu- 
monia is promoted by the exposure of the patient, while 



698 LUNG COMPLICATIONS IN ANESTHESIA 

under the influence of the anesthetic, by allowing the 
coverings to slip off from his body and limbs, or by 
allowing him to lie in coverings or clothing saturated 
with blood or with fluids used during the operation. It 
is exceedingly important that a patient under an anes- 
thetic should be kept warm and dry. Various devices 
have been designed for keeping the patient warm by 
appliances connected with the operating table. These 
are often useful, but caution should be exercised lest 
the patient, while unconscious, should be burned by 
such appliances. 

As just stated, pulmonary congestion and post- 
operative pneumonia are frequent serious occurrences 
after prolonged anesthesia, especially after prolonged 
etherization. Various factors have been assigned an 
influence in the etiology of these pulmonary conditions. 
Among others, it has been alleged that probably the 
chilling of the respiratory organs by the evaporation 
of the anesthetic has an important part. It has been 
observed that anesthetics seemed to act better in warm 
climates and in warm weather. From these observa- 
tions it has been deduced that if the anesthetic is 
warmed before it is administered, there will be less 
danger of pulmonary sequelae. During the last ten or 
fifteen years many anesthetists have insisted on having 
the anesthetic itself, or the vapor, warmed before it is 
inhaled by the patient. This may be accomplished in 
various ways. For ordinary use, the warming of the 
can of ether or the bottle of chloroform to about the 
temperature of the body would seem to be most desir- 
able. The inhalation of an anesthetic at this tempera- 
ture results in less irritation in the throat at the begin- 
ning of anesthesia, the early accession of complete 
anesthesia, less of the anesthetic is needed, and hence 
fewer after effects. 

Many patients complain of backache after an opera- 
tion. This is probably due in many cases to straining 
of the muscles of the back on account of the back not 
being properly supported while the patient is uncon- 
scious. In order to avoid this a small pillow should 
always be placed under the lumbar region of the patient 
while he is on the operating table. 



DISINFECTION 699 

The question frequently arises whether to anesthe- 
tize a patient in the operating room and on the oper- 
ating table, or in an adjoining room. With reference 
to this it should be urged that the less a patient is 
moved about after the administration of the anesthetic 
is commenced, the better. On the other hand, a nervous 
patient should generally be anesthetized in an adjoin- 
ing room, and if possible, on a stretcher or rolling 
table, so that he may be transferred to the operating 
room and then to the operating table with the least 
possible general disturbance. 

CONTRAINDICATIONS OF ETHER 

Ether is contraindicated if there is present disease 
either of the lungs or kidneys. Other contraindications 
to the use of ether are chronic alcoholism, aneurysm, 
very high blood pressure, and an atheromatous condi- 
tion of the arteries. 

DISINFECTION 

The control of infectious diseases is inseparably 
connected with disinfection. The rational use of dis- 
infection began with the growth of our knowledge 
of bacteriology. "To disinfect," says Hasseltine 
(Pub. Health Reports, 1915, xxx, p. 2049), "is to free 
from infectious or contagious matter ; to make innocu- 
ous. To fumigate is to apply smoke, gas or vapor." 
He therefore considers as disinfecting measures those 
which attack the specific cause of disease; as fumi- 
gating measures those which by the use of smoke, gas 
or vapor, attack the specific cause indirectly through 
the destruction of intermediate hosts or carriers, other 
than man, such as mosquitoes, rats, fleas, flies, etc. 

USE OF DISINFECTANTS DURING THE COURSE 
OF DISEASE 

If disinfection is properly carried out at the bedside 
the need of much terminal disinfection is obviated. 
The secretions and excretions which the patient gives 
off are the source of infection through the virulent 
organisms contained in them. Although it is unneces- 
sary to disinfect all discharges in some diseases, it is 
better to err on the safe side and to disinfect all of 
them. 



700 LIQUID DISINFECTANTS 

Sputum, nasal and other discharges should be 
received on cheap cloths and then incinerated. Solu- 
tions containing 5 per cent, phenol, 1 per cent, tricresol 
and compound cresol solution are efficient disinfectants. 
For feces and urine, about one gallon of boiling water 
may be added to a stool, which is then covered and 
allowed to stand until cool. Better still, however, is the 
following method devised by Prausnitz. A small 
amount of hot water is added to the stool, then fresh 
quicklime. The process of slaking raises the tempera- 
ture and maintains it above the thermal death point of 
most organisms. 

Bath water is easily disinfected by the addition of 
crude carbolic acid. 

Soiled bedding and clothing are best disinfected by 
removal to a steam disinfecting chamber. Where this 
is unavailable, immersion in boiling water for five 
minutes, or in 5 per cent, phenol solution for several 
hours is efficient. 

Mattresses, if infected, can be disinfected only by 
steam under pressure. Otherwise they should be 
burned. 

Such articles as leather, morocco, or india rubber, 
furs, books and similar objects may be disinfected by 
long continued dry heat, 120 C. for an hour. Unless 
they are of considerable value, however, it is better to 
burn them. 

LIQUID DISINFECTANTS 

Mercuric Chlorid. — The solutions of mercuric 
chlorid are extremely poisonous. Frequent poisoning 
has made their use in the home undesirable unless 
carefully guarded. Tablets are now prepared colored, 
threaded, in odd shapes, and put up in various ingen- 
ious warning packages. In strength of 1 : 1,000 it 
destroys practically all organisms ; 1 : 500 kills spore- 
bearing bacteria. Solutions are corrosive to metal 
containers. The following 'mixture, which contains 
mercuric chlorid in a strength of 1 : 1,000, is recom- 
mended by Parkes : 

Mercuric chlorid V» ounce 

Hydrochloric acid 1 ounce 

Anilin blue dye 1 grain 

Water .. . . 3 gallons 



TERMINAL DISINFECTION 701 

Phenols. — This group, of which carbolic acid is the 
one most widely known, forms the basis of most com- 
mercial disinfectants. A 5 per cent, solution of car- 
bolic acid is usually employed. 

Copper Sulphate. — In 5 per cent, solution this salt 
acts as a strong disinfecting agent and through its 
power to absorb ammonia and hydrogen sulphid, it is 
a good deodorant. 

Zinc Chlorid. ~ A 10 per cent, solution of zinc chlorid 
to which a little hydrochloric acid has been added is 
used for spore-forming bacteria. A 5 per cent, solu- 
tion suffices for other organisms. Its action in gen- 
eral resembles that of copper sulphate. 

Potassium Permanganate. — The solutions of potas- 
sium permanganate stain everything with which they 
come in contact. At least a 5 per cent, solution is 
required for killing most organisms. The drug is a 
rather expensive one. 

Chlorid of Lime. — This substance has been men- 
tioned for use in disinfecting stools. It is important 
that the large masses of the stool be broken up, in 
order that the lime have a chance to act on the organ- 
isms. Not less than a 1.5 per cent, solution of th* 1 
powder (about 2^4 ounces to the gallon) should be 
employed. 

Formaldehyd. — This substance is used chiefly as 
liquor formaldehydi, about 40 per cent, strength. It 
is chiefly used for its power to produce a disinfect- 
ing gas. 

TERMINAL DISINFECTION 

With reference to the more common infectious dis- 
eases, such as diphtheria, scarlet fever and measles, 
some authorities believe that terminal disinfection is 
unnecessary. Their claim is based on the belief that 
conditions are unfavorable for the multiplication of 
organisms outside the body and that such organisms 
die shortly after their removal from animal tissue. 
The handbook of the Bureau of Infectious Diseases 
of the New York Department of Health says that "in 
diphtheria and measles, when a patient recovers the 
sick room is thoroughly cleaned and aired." 



702 TERMINAL DISINFECTION 

Cleansing is a good method of terminal disinfec- 
tion. The floors and wood work, all mouldings, ledges 
and window casements should be scrubbed. A vacuum 
cleaner may be applied to the walls and ceiling, if such 
an apparatus is available. After cleaning, renovation, 
including painting, renewal of wall paper and calci- 
mining is a valuable measure. 

Wherever there is doubt as to the thoroughness 
with which cleansing and renovation are accomplished, 
as well as bedside disinfection, and wherever possible 
without too great inconvenience, terminal fumigation 
should be done. Hasseltine recommends in combating 
disease carried by animal hosts, fumigation with sul- 
phur dioxid. The best results, he suggests, are ob- 
tained by fumigating all rooms of the structure simul- 
taneously. Five pounds of sulphur per 1,000 cubic 
feet are sufficient, and should be placed in a thin layer 
so as to burn rapidly. If fumigating only to destroy 
vermin, moisture is not necessary. Exposure of four 
to twelve hours is desirable. 

In those diseases that are apparently non-insect borne 
and communicable, formaldehyd may be used. This 
should always be properly applied. It should be used 
at a temperature of 65 F. or higher, and with a rela- 
tive humidity of 65 per cent, at the beginning of the 
process. Humidity and the required temperature may 
be obtained by boiling water in the room. If possible, 
all the gas liberated should be confined to the room 
fumigated. The following method devised by Dixon 
is a good one for the liberation of formaldehyd gas. 

Briefly, the procedure is as follows : Ten ounces of 
liquor formaldehydi and 5 ounces of potassium per- 
manganate are sufficient for 1,000 cubic feet of space. 
A large receptacle should be used, to avoid spattering, 
and this should be placed on a noncombustible sur- 
face. If there be not sufficient moisture present there 
will be some danger of the dry gas igniting. Several 
receptacles in different parts of the room are more 
effective than one large container. The permanganate 
is placed in the container and the formaldehyd poured 
over it. The reaction is shown by ebullition of the 
fluid, slight or marked according to its temperature. 
When once started it continues until all available for- 
maldehyd has been liberated. 






ANAPHYLAXIS 703 

In New York City, this method is modified by using 
75 gms. of permanganate in 90 c.c. of water, hot if 
possible ; then 30 gms. of paraformaldehyd are added. 
This is sufficient for 1,000 cubic feet. This method 
makes less weight to carry, as the water is obtained at 
the place where disinfection is to be done. The para- 
formaldehyd is more stable than formaldehyd solu- 
tion, the latter seldom containing the required 40 per 
cent. 

Dixon reported favorable results by substituting 
sodium dichromate and sulphuric acid for potassium 
permanganate. The acid and formaldehyd solution 
are mixed and allowed to cool. This solution is then 
poured over the crystals of sodium dichromate, spread 
in a thin layer in a large container. The mixture is : 

Sodium dichromate oz 10 

Saturated solution formaldehyd gas.... pint 1 
Sulphuric acid, commercial oz 1.5 

ANAPHYLAXIS— ALLERGY 

PROTEIN POISONING 

The fact that bacteria could cause protein poisoning 
was first noted and the condition described, in 1903, by 
Victor C. Vaughan of Ann Arbor. Protein poisoning 
is the cause of most urticarial conditions, of many of 
the. skin eruptions, of many of the simple, socalled 
febricula (a name applied to a fever lasting one or two 
days with no positive diagnosis determinable), and all 
of these disturbances are really forms of allergy. " 

Some protein poisons may cause a lowered or sub- 
normal temperature, rather than fever. This is appar- 
ently due to a marked dilatation of the peripheral 
blood vessels, especially of the splanchnic area, similar 
to that in shock. With other protein poisonings there 
may be, for several days, an irregular temperature 
with morning remissions. If such poisonings persist 
and the toxins are not rapidly expelled, neutralized 
or destroyed, there will be an increased elimination 
of nitrogen and a progressive loss of weight. 

The symptoms of many diseases are due to the 
socalled "parenteral" ingestion of proteins. Hay-fever 
and paroxysms of asthma are caused in sensitive indi- 
viduals by the pollen of different plants, the emanations 



704 ANAPHYLAXIS 

from different animals, or the dust or odors of many 
kinds of substances. Any susceptible individual may 
be sensitized, so to speak, by one or more of these irri- 
tant causes and not by others. The inhalation of some 
substances in almost intangible amounts may cause 
serious inflammation of the upper air passages and 
even of the bronchial tubes. 

Many drugs taken internally may sensitize individ- 
uals who have peculiar idiosyncrasies against them, and 
may cause, primarily, gastric and duodenal irritation, 
and secondarily, disturbances similar to protein poison- 
ing (such as urticaria and swelling of the mucous 
membranes), which may become serious, as occasion- 
ally seen with quinin, salicylates, antipyrin and the 
coal-tar products. Many of the socalled genito-urinary 
stimulants of the copaiba class may cause considerable 
irritation and eruption of the skin. 

As indicated by Cooke (Jour. A. M. A. 73:759, 
1919), Coca's classification of hypersensitiveness into 
"anaphylaxis" and "allergy" will serve to clarify this 
whole field, which has been confused by the attempt to 
explain naturaland artificial hypersensitiveness on the 
same basis. - 

Anaphylaxis is an antigen antibody reaction, arti- 
ficially induced by immunologic processes. Allergy is 
used to express the natural hypersensitiveness of the 
individual not produced by immunologic processes", as 
the exciting agents or allergens are in many cases not 
capable of producing antibodies. For example, the 
natural hypersensitiveness of the human being to pol- 
lens, the clinical reaction to which is known as hay- 
fever, is admittedly allergic. In experiments carried 
on with Coca and Flood, Cooke and Vender Veer could 
not demonstrate antibody in the individual during an 
attack or after injection of pollen extract by passive 
trans ferj nor could antibody be produced in the guinea- 
pig itself. In other words, the extract is nonantigenic. 
Other substances, such as glue and certain drugs like 
acetylsalicylic acid, to which individuals react pecul- 
iarly, are also nonantigenic. To be sure, many of the 
substances to which the human being does show clinical 
hypersensitiveness are capable of forming antibodies. 
Hence the confusion between the natural hypersensi- 
tiveness or allergy and the artificial or anaphylaxis. 



ANAPHYLAXIS 705 

Living bacterial cells, like other living cells, must 
form ferments to prepare their food for absorption. 
Consequently, as described by Vaughan, for a given 
bacterium to be poisonous to the human animal, for 
instance, it must have the ability to split up and feed 
on the proteins of the human being ; otherwise bacteria 
cannot grow and cannot harm the host. Another pre- 
requisite to such poisonings is that the ferments in man 
must not be immediately destructive to the invading 
bacterium, although ultimately antibodies may be 
formed in sufficient quantities to destroy it. A bac- 
terium, then, able to digest the proteins in man renders 
this host susceptible to its poisoning unless he has 
been previously protected, either by a previous infec- 
tion from the specific bacterium or by a previous inocu- 
lation or vaccination with the germ or its products 
which so promotes the formation of antibodies or anti- 
ferments that it renders the individual immune. This 
is the scientific basis of vaccination and protective 
inoculation. 

The value of vaccine treatment is due to the fact 
that the general system is not producing ferments suf- 
ficient to eradicate the special bacterium and its poison, 
and the inoculation so stimulates the general produc- 
tion of antibodies or ferments that the local disease is 
stopped and later eradicated. On the other hand, if a 
person is suffering from a general poisoning or infec- 
tion, such vaccines are of doubtful value or may be 
actually harmful by over stimulating the already worn- 
out antagonistic cells, and the individual is thus really 
injured by such vaccination; therefore the frequent 
and careless use of vaccines is deplorable and often 
inexcusable. 

If proteins are naturally digested in the stomach and 
intestines and are absorbed only as the molecular forms 
that normally reach the blood, no sensitizing or anaphy- 
laxis or intoxication will occur. If, however, the pro- 
teins are absorbed before they reach their final disin- 
tegration stages and are then digested parenterally (that 
is, outside of the intestine), or if they reach the blood 
through other channels or are injected directly into the 
tissues, such poisoning or "reaction" occurs, attended 
by more or less fever, nervous irritability, increase in 



706 DEFINITION OF ANAPHYLAXIS 

the number of the white corpuscles, changes in the 
blood plasma, kidney irritation, and frequently diar- 
rhea. The system, however, soon produces active or 
immune bodies to combat the specific ferment. 

DEFINITION 

By the word "anaphylaxis" is understood generally 
the more severe phenomena that appear when an ani- 
mal previously influenced (sensitized) by a foreign 
protein, introduced into the blood and tissues by 
injection or otherwise, after a suitable interval again 
receives the same protein into its blood and tissues 
as the result of injection or otherwise. Anaphylactic 
shock in the guinea-pig injected for experimental pur- 
poses is the classical example. As these phenomena 
are regarded currently as the result of an intoxication 
with the products of protein splitting, anaphylaxis may 
be looked on as a protein intoxication occurring when 
a prepared animal receives the proper protein into its 
system. 

At first the word anaphylaxis was used to describe 
the condition in which severe, violent phenomena occur 
on reintroduction of toxic proteins (eel serum, actinea 
poison) in animals previously injected with these sub- 
stances for purposes of immunization. This was con- 
trary to expectation; the previous injections, it had 
been assumed, would produce a condition of protec- 
tion — a prophylaxis; as the directly opposite action 
resulted, the word anaphylaxis, meaning the reverse of 
prophylaxis, was coined to designate the condition. 
Before long, hypersusceptibility was introduced as 
synonymous with anaphylaxis. As a clearer insight 
into the nature of the condition was gained, especially 
through the work of von Pirquet on serum disease in 
man, it developed that in reality the reverse of pro- 
phylaxis or hypersusceptibility to poisonous substances 
is not concerned, but a change in the powers of the 
body to react on the introduction of foreign proteins. 
In order to indicate the nature of this conception, von 
Pirquet coined the word "allergy," which means altered 
reactivity. Novy and DeKrinf have coined the word 
"taraxy" from the Greek word meaning "a distur- 
bance." The anaphylactic protein poison, also called 



MANIFESTATIONS OF ANAPHYLAXIS 707 

the allergic substance, and the anaphylotoxin they 
would call "taraxin," i.e., the disturbing substance. 
At present there seems to be general agreement that 
phenomena as different as the experimental anaphy- 
lactic shock in guinea-pigs, the various manifestations, 
mild and severe, of serum disease in man, various 
"food idiosyncrasies," such as egg asthma, poisoning 
by cow's milk, etc., and the tuberculin and similar 
reactions are all due to an altered reactivity of the 
body, altered by previous influence of the foreign pro- 
teins concerned on the antibody-producing tissues. 

MANIFESTATIONS 

The length of time before the occurrence of hyper- 
sensitiveness or sensitization varies ; the poisoning may 
be acute, as in socalled "ptomaine poisoning" or in 
that which occurs from some such toxin as is found in 
toadstools ; or it may require a number of days for the 
person affected to be sensitized. Sensitization from a 
serum injection or from the absorption of some pro- 
tein irritant may not happen until after a series of 
days, perhaps a week, and this sensitization will often 
not be recognized until a second injection (the intoxi- 
cating dose) of the same serum is administered, or 
until more of the same protein poison is absorbed, 
when reaction becomes evident and is sometimes seri- 
ous in its outcome. Therefore, it cannot be too care- 
fully noted that injection of prophylactic or antitoxic 
serums should ordinarily not be repeated too long after 
the first injection has been given. This is not always 
true of all antitoxins or all bacterins, but it is more 
or less constantly in evidence. Sometimes the system 
becomes tolerant to this irritant, and a larger dose, 
given to obtain a desired reaction, will be borne. In 
other instances the patient becomes hypersensitive, and 
the repetition of a previously harmless dose may cause 
an intense reaction. This has occurred with diph- 
theria antitoxin a number of times, and would occur 
with any horse serum in patients who are susceptible 
to, and are always hypersensitized by, emanations or 
dust from horses. 

Persons peculiarly susceptible to horse serum may 
develop bronchial edema and severe symptoms within 



708 MANIFESTATIONS OF ANAPHYLAXIS 

a few minutes or hours after an injection of diph- 
theria antitoxin ; or, in certain instances, they may not 
develop the asthma, urticaria, joint pains and fever 
until after a series of days. Such late symptoms are 
not generally dangerous, although albumin may appear 
in the urine, but generally the kidneys rapidly recover 
and all the symptoms disappear. Other persons may 
have an intense local reaction to an injection of anti- 
toxin or vaccine out of all proportion to the injury 
caused and later may show some of the general symp- 
toms. Such cases are very troublesome and more or 
less serious, but rarely cause death. 

When antitoxin is indicated in diphtheria, or horse 
serum in hemorrhage, one should be sure to inquire 
whether or not the patient is an asthmatic or a sufferer 
from hay-fever, and especially if horse emanations 
cause either of these conditions. A preliminary injec- 
tion of a small dose, perhaps just a few minims beneath 
the skin, will indicate whether there is a marked sus- 
ceptibility. This phase of the subject has been fully 
discussed under the subject of antitoxin in diphtheria. 

This reaction of the blood, that is, anaphylaxis, to 
different poisons, seems to be the cause not only of the 
symptoms which follow vaccination against smallpox, 
typhoid fever and other diseases or infections, but also 
of the symptoms of hay-fever induced by different 
pollens, varieties of dust or odors. It is the cause of 
asthma in many persons, of the urticaria produced in 
susceptible individuals by shellfish, buckwheat or 
strawberries, and of the symptoms of sensitization or 
anaphylaxis which sometimes occur even from such 
ordinary foods as veal, pork, eggs, some kinds of 
cheese and milk. 

It seems also, with our great knowledge of this 
blood disturbance, that quite probably the skin erup- 
tions of the exanthems, of typhoid fever, and even of 
primary syphilis may be due to this hypersensitizing of 
the blood by the proteins of the specific bacteria. Our 
recognition of the anaphylactic temperature caused by 
serums and toxins suggests that the fever process of 
the various infections may also be due to the protein 
poisoning caused by the germ of infection. 



TREATMENT OF ANAPHYLAXIS 709 

TREATMENT 

Discussion of the treatment of these specific sensi- 
tivities would lead us astray, but the symptoms attrib- 
uted to the poisoning protein in the blood are more or 
less the same, namely, fever, irritation of the central 
nervous system, cutaneous irritability and perhaps 
eruption, more or less muscle pains and concentration 
of the urine with kidney irritation, lumbar backache, 
and either constipation or a diarrhea that shows bowel 
irritation without complete evacuation. In some 
instances vomiting is present, especially in children, 
and headache is frequent or constant, dependent on 
whether the absorption of the poison is intermittent 
or continuous. 

Whatever the infection or irritant that causes these 
symptoms may be, the general treatment is the same, 
namely, whatever of the poison is still in the intestine 
should, if possible, be removed by a free, non-irritating 
catharsis by castor oil, calomel, or a saline, as advis- 
able. It is quite possible that more of certain kinds 
of intestinal poisons may be absorbed under the influ- 
ence of an oil than would be if a saline is adminis- 
tered. If it is a poison to which the patient is sus- 
ceptible, he certainly should receive no more of the 
irritating food. If the disturbance is due to the pro- 
teins of some specific germ, he should receive only 
such nutriment as is easily digested, and therefore less 
likely to furnish incompletely disintegrated protein 
products for absorption, thus to add more irritants 
to the already disturbed blood. Consequently, indi- 
vidual idiosyncrasies should be learned and the signs 
of indigestion noted ; the foods that probably will 
digest most readily and are not too rich in proteins 
are the only ones that the patient should be allowed. 

Novy and DeKruif on the basis of extensive studies 
have advocated the administration of sodium bicarbon- 
ate or, preferably, sodium acetate in large doses — from 
3 to 5 gm. dissolved in a half glass of water — in the 
treatment of chronic sensitivity. These doses are 
given at intervals of from one-half hour to an hour 
during the day. The object of this treatment is to 
raise the alkalinity of the blood to a maximum and to 
sustain this degree of alkalinity. It is also advised 



710 CALCIUM IN ANAPHYLAXIS 

as a prophylactic in patients with a tendency to 
eclampsia or to food reaction of any kind. As recom- 
mended under the treatment of syphilis, the injection 
of large doses of alkali before giving a dose of arsphen- 
amin (salvarsan) may be of service in preventing a 
reaction to this drug. 

The next object is to dilute the poison already in 
the blood by the administration of large amounts of 
water, perhaps medicated, acidulated, alkalized, car- 
bonated or plain, as seems indicated. The greater the 
amount of urine passed, and the freer the perspiration, 
the sooner, in all probability, will the toxins be elimi- 
nated, unless they are produced in overwhelming quan- 
tities. 

The skin should be frequently soothed with warm 
water (often best made alkaline with sodium bicar- 
bonate) sponging and then powdering with a simple 
bland powder, such as starch. An irritated, erupted 
skin should not be sponged with alcohol, which dries 
the skin and will cause more irritation. The more 
moisture there is in a skin with an urticarial or exan- 
thematous eruption, the less is the irritation and itch- 
ing. The temperature is also more rapidly reduced by 
evaporation. If the fever is excessively high and must 
be reduced, of course the usual hydrotherapeutic mea- 
sures should be inaugurated. 

calcium 

The nutritional value of calcium and its necessary 
participation in many functions of the body is described 
under that head. The relationship of diminished cal- 
cium content of the blood to some angioneurotic ede- 
mas and to some of the urticaria-like localized swell- 
ings and edemas, has been shown by investigators. It 
seems to be a clinical fact in many cases that these 
exudates and symptoms of anaphylaxis are prevented, 
or are quickly improved, by the administration of 
calcium. Experimental evidence as to the value of cal- 
cium in preventing anaphylaxis is rather contradictory. 

DRUGS WHICH CAUSE ERUPTIONS 

Urticarias, erythemas and scarlatiniform eruptions 
may be caused by belladonna, salicylic acid and arsenic 
or any of their salts or preparations; by antitoxin, 



DRUG ERUPTIONS 711 

many of the volatile oils and drugs containing them 
(as copaiba, santal oil, turpentine) ; by some of the 
synthetic compounds (as antipyrin, sulphonal, etc.) ; 
by chloral, quinin and its salts, and by opium and 
many of its alkaloids or preparations. These erup- 
tions appear in some patients after a single therapeutic 
dose of any of these drugs; in others only when the 
drug is pushed, or when it has been given for some 
time. The frequency of idiosyncrasy against these 
drugs follows about the order in which they are named. 
Arsenic will rarely cause an eruption, unless it is 
pushed to full physiologic action. Some patients 
acquire a drug tolerance and no subsequent eruptions 
occur after the first dose or two. This is typically true 
of some persons who are -susceptible to quinin. 

Unless the drug is being pushed to full physiologic 
action with a definite object, or a tolerance is expected 
and desired or the discomfort is unimportant, the drug 
should be stopped, a cathartic given, and soothing, 
bland mucous membrane sedatives should be admin- 
istered, such as bismuth subcarbonate, sodium bicar- 
bonate, milk of magnesia or slippery elm or flax-seed 
infusions. Even milk and starch water are sometimes 
very efficient sedatives to the mucous membrane of 
the stomach and upper intestine, if it has been irri- 
tated by a drug. Of course, it is possible that the drug 
has caused anaphylaxis and the irritant is already in 
the blood. Then the treatment consists of large 
amounts of water, a bland diet, alkalies such as potas- 
sium citrate, large doses of sodium bicarbonate, and 
perhaps calcium in some form. 

Bromids and iodids frequently cause skin eruptions, 
occasionally after the first dose, but generally after a 
series of doses. An eruption quite generally occurs if 
these drugs are at all continuously given. Some 
patients, like epileptics or syphilitics, who are given 
large doses of bromids and iodids for a long time, 
become tolerant and do not have the skin eruptions, 
unless the dosage is very large. The iodid eruption is 
likely to be papular, but is rarely pustular. The bromid 
eruption is papular and frequently pustular, and the 
bromids may cause serious skin eruptions. It is some- 
times thought that when arsenic is given coincident- 



712 VACCINE THERAPY 

ally with bromids this troublesome eruption is less 
likely to occur. It also should be remembered that if 
sodium chlorid is removed from or greatly reduced 
in the diet of the patient, such large amounts of 
bromids as were once given are unnecessary. There- 
fore, the eruption is less likely to occur. The iodids 
cause eruptions less often than the bromids. The 
eruption from either drug rarely causes itching, but 
it takes some time for the eruption to disappear, even 
when the drugs have been discontinued. 

The treatment of these eruptions is to stop the drugs, 
if possible, to cause thorough bowel elimination, to 
give hot baths or body bakes or electric light baths, 
and massages, as all tend to promote a more healthy 
condition of the skin. In fact, the bromid eruptions 
are less likely to occur if the skin is frequently cleansed 
and massaged during administration of large doses of 
the drug. 

VACCINE THERAPY 

"If at the present time ten years of public notoriety 
have passed over any doctrine professing to be of 
importance in medical science, and if it has not suc- 
ceeded in raising up a powerful body of able, learned, 
and ingenious advocates for its claims, the fault must 
be in the doctrine and not in the medical profession." 
This old criterion of Holmes, says Leake {Jour. A. 
M. A. 71: 631, 1917), is applicable to bacterial vaccine 
therapy, for though Fraenkel's work dates back almost 
three decades and Wright's eighteen years, in this 
country it was not until about thirteen years ago that 
any great degree of notoriety attached to the subject. 
The profession generally was about to grant vaccine 
therapy, at least autogenous vaccines, a more or less 
definite place when the new mass of data regarding 
nonspecific reactions began to appear and to cause 
grave doubts as to what were formerly regarded as 
fundamental principles. 

In this consideration the use of vaccines in prophy- 
laxis will not be considered. Against typhoid they are 
undoubtedly efficacious ; in whooping cough they have 
some value, and in a few other instances they are of 
doubtful efficacy. 



AUTOGENOUS VACCINES 713 

It is the general impression that a well prepared 
autogenous vaccine is superior to a stock vaccine in 
securing effective results. On the other hand, com- 
mercial laboratories holding federal licenses and 
manufacturing stock vaccines, claim for their products 
superiority as to sterility and content of preservative, 
and less likelihood of containing toxic protein products. 
For the autogenous vaccine it* may be argued that there 
are numerous individual strains of bacteria and there- 
fore autogenous vaccines possess greater specificity. 
At the same time, it has been argued that the entire 
effects are now specific and due to the reaction created 
by the injection of foreign bacterial protein. 

NEED FOR CONTROL OBSERVATIONS 

As indicated by Leake, the literature abounds with 
observations on this form of therapy, but the vaccine 
was administered for the most part without controls. 
It is obvious that the tendency is to report favorable 
results, while the series of nonsuccessful cases are less 
likely to be published. In some very excellent experi- 
ments in which the injections of vaccines were used on 
some patients treated side by side with others who 
did not receive vaccines, and covering typhoid fever 
(Whittington), pertussis, (Von Sholly), and influenza, 
(McCoy), it was shown that the vaccine treated cases 
did no better and in some instances did worse than 
those not receiving vaccines. Furthermore, Billings, 
who studied many cases of chronic arthritis, reported 
that a personal and general hygienic management did 
quite as much without as with vaccines ; and that when 
such management is neglected and treatment left to 
vaccines alone, the patients are harmed. This view 
may seem pessimistic, yet it is based on a review of an 
extensive literature which was found to be marked 
primarily by a "will-to-believe" rather than a critical 
judgment. 

AUTOGENOUS VACCINES 

Autogenous vaccines are prepared from bacteria 
isolated from the patient who is to receive the vaccine. 
""Assuming that we have a case which clinically is suit- 
able for treatment by active immunization," says Irons, 
"we may inquire what preparation of bacteria will be 



714 MIXED VACCINES 

most efficient in stimulating the inactive "forces of 
immunity. The researches of recent years indicate 
that one of the chief elements in the chronicity of an 
infectious process is a change in the infecting organism 
by which it becomes less susceptible to the attack of 
the forces of immunity of the host, and that this bac- 
terial resistance or 'fastness' may be as important as 
the deficiency in the formation of antibodies of the 
host. Another similar change in the infecting organ- 
ism, the acquirement of 'organ specificity' by which 
through long sojourn in a particular organ of an ani- 
mal, or series of animals, the invader develops a special 
aggressiveness for that organ, must also be reckoned 
with. If artificial active immunization is to be effec- 
tive, it should take cognizance of all, or of as many 
of these elements as possible, and hence a vaccine 
should be derived from any organism possessing the 
properties of those concerned in the infectious process 
— an autogenous vaccine." 

:-*» • ,1, L^^mj^m^^ m '- '■* r _ " r *v r •• 7T 

STOCK VACCINES 

Stock vaccines are suspensions of killed bacteria in 
salt solution, oil (lipovaccines) or water, usually with 
a small amount of preservative, phenol or tricresol. 

MIXED VACCINES 

Mixed vaccines are made by securing all the micro- 
organisms present in a secretion or in a material, or by 
mixing stock vaccines in various combinations. Their 
value is questionable. It has been said that the resort 
to mixed vaccines, particularly to mixed stock vaccines, 
is either a confession of ignorance of the exact nature 
of the infection and misapprehension of the principles 
of immunity or an evidence of indifference and laziness 
on the part of the physician using them. It were more 
advisable to use a known unmixed stock vaccine, a 
carefully studied polyvalent vaccine, or a single purified 
protein. As a rule, some one organism plays a pre- 
dominant role in an infectious process. In some cases, 
as in sinus infection complicated by arthritis or mas- 
toiditis, two or more organisms may be associated in 
producing the disease condition. When this etiologic 
association has been determined by actual bacteriologic 



THERAPEUTIC USE OF VACCINES 715 

examination a mixture of two vaccines may be tried 
provided vaccines are at all indicated. Unless based 
on preliminary bacteriologic examination, the method 
is irrational. 

DATING OF PRODUCTS 

Federal regulations require that each package of 
biologic products be stamped with an expiration date 
"beyond which the contents cannot be expected beyond 
reasonable doubt to yield their specific result." Such 
products should be kept in cold storage. 

THERAPEUTIC USE OF VACCINES 

Woolley says that infectious processes in general are 
suitable for treatment by active immunization ( 1 ) if 
they are localized, i. e., confined to one or more isolated 
lesions and not associated with bacteriemia; (2) if 
they are more or less chronic. Based on a study of the 
literature he concludes with Moody (Jour. A. M. A. 
74: 391, 1920) that autogenous vaccines seem to be 
useful in the' following infectious disorders : 

1. Furunculosis and localized abscesses in soft tissues. 

2. Acne vulgaris. 

3. Colon bacillus pyelitis and cystitis. 

4. Chronic gonorrhea and gonorrheal rheumatism. 

5. Chronic bronchitis. 

6. Bronchial asthma of bacterial origin. 

Vaccines seem to be of little or no value, he says, in : 

1. Infection of bone or infections in cavities with rigid walls. 

2. Infection of the intestinal tract. 

3. Infection of the uterus and adnexa. 

Vaccines are contraindicated in: 

1. Acute infections and infectious diseases. 

2. Septicemia and pyemia in the acute stages. 

3. Malignant endocarditis. 

Moody has also outlined the following rules : Begin 
with a dose small enough to avoid a generalized reac- 
tion, and gradually increase this dose to the point at 
which perhaps only a slight local reaction occurs. At 
first one may give the injections every day to determine 
what is the proper dose for the patient being treated. 
When this point is determined, one should continue to 
give increasing doses at three or four day intervals 



716 VACCINATION AGAINST SMALLPOX 

until one is giving at each injection not more than one 
billion organisms. Massive doses of killed organisms 
are likely to be quite toxic and produce harmful rather 
than beneficial results. As a matter of fact, under such 
conditions it is possible to lower greatly the normal 
resistance of the person treated. 

It must be remembered also that the body cells of 
persons with acute infections are. quite sensitive to 
foreign protein injections. This is important, and phy- 
sicians using vaccine therapy should bear it in mind and 
treat such patients with caution. 

In prophylactic immunisation, especially against 
typhoid, persons with chronic malaria, tuberculosis, 
bronchitis, nephritis, etc., are quite likely to react so 
severely to the ordinary injection that harmful results 
not infrequently follow. 

VACCINATION AGAINST SMALLPOX 

THE KIND OF VACCINE TO USE AND HOW TO USE IT 

The United States Public Health Service, in Public 
Health Reports for November, 1917, advises the fol- 
lowing procedure in order to secure the best results 
from vaccination and to prevent possible complications. 

I. THE VACCINE 

The freshest possible vaccine should be obtained. 
All vaccine packages, pending use, should be kept in 
a metal box in actual contact with ice. 

II. THE VACCINATION 

Vaccination should never be performed by cross 
scratching or scarification, but by one of the methods 
described below. If a prompt "take" is very necessary, 
as in case of direct exposure to smallpox or if the first 
attempt has been unsuccessful, three or four applica- 
tions of the virus should be made, but the insertions 
should be at least an inch apart. Whichever method 
is used, a control area may be first treated similarly, 
but without the virus, in order to estimate the amount 
of pressure necessary for insertion and in order to 
demonstrate a possible early immune reaction in pre- 
viously vaccinated individuals. 



VACCINATION AGAINST SMALLPOX 717 

Preparation. — The skin of the upper arm, in the 
region of the depression formed by the insertion of the 
deltoid muscle, should be thoroughly cleansed with soap 
and water if not seen to be clean, and in any case with 
alcohol or ether on sterile gauze. 

After evaporation of the alcohol or ether, a drop of 
the virus should be placed on the cleansed skin. To 
expel the virus from a capillary tube, the tube should 
be pushed through the small rubber bulb which accom- 
panies it, wiped with alcohol, and one end broken off 
with sterile gauze ; the other end may be broken inside 
the rubber bulb. The hole in the latter should be 
closed with the finger as the bulb is compressed to 
expel the virus. 

The under surface of the arm is grasped with the 
vaccinator's left hand so as to stretch the skin where 
the virus has been placed. The skin is kept thus 
stretched throughout the process. 

Methods. — (a) The Method of Incision, or Linear 
Abrasion : By means of a sterilized needle or other 
suitable instrument, held in the right hand, a scratch, 
not deep enough to draw blood, is made through the 
drop of virus, one-quarter inch long and parallel with 
the humerus. The virus is then gently rubbed in with 
the side of the needle or other smooth, sterile instru- 
ment. Some blood-tinged serum may ooze through the 
abrasion as the virus is rubbed in, but this should not 
be sufficient to wash the virus out of the wound. 

(b) The Drill Method: A sterile drill, such as is 
used for the von Pirquet cutaneous tuberculin test, 
shaped like a very small screw driver with a moderately 
sharp end not more than 2 mm. wide, is held between 
the thumb and middle finger, and with a twisting 
motion and moderately firm pressure, a small circular 
abrasion, the diameter of the drill, is made through the 
drop of virus ; this should draw no blood. 

(c) The Multiple Puncture Method: A sterilized 
needle is held nearly parallel with the skin, and the 
point pressed through the drop of virus so as to make 
about six oblique pricks or shallow punctures, through 
the epidermis to the cutis, but not deep enough to 



718 VACCINATION AGAINST SMALLPOX 

draw blood. The punctures should be confined to an 
area not more than one-eighth inch in diameter. 

With Methods a and b it is advisable to expose the 
arm after vaccination to the open air, but not to direct 
sunlight, for fifteen minutes before the clothing is 
allowed to touch it. With Method c the virus may be 
wiped off immediately. 

III. THE VACCINATION WOUND 

1. The original vaccination wound should be made 
as small as possible, and all injury to the vaccinated 
arm should be guarded against. Any covering which 
is tight, or more than temporary, tends to macerate the 
tissues during the "take." This is to be avoided. No 
shield or other dressing should be applied at the time 
of vaccination. Customary bathing and daily washing 
of the skin may be continued, so long as the crust does 
not break. The application of moisture to the vacci- 
nated area should not be enough to soften the crust. 

If an early reaction of immunity is to be watched 
for, the patient should report on the first, second, fifth 
and seventh days after vaccination. Otherwise, the 
patient should report on the ninth day, or sooner if 
the vesicle, pustule or crust breaks. Every effort 
should be made to prevent such rupture. However, 
should the vesicle, pustule or crust break, and the 
wound thus become open, daily moist dressings with 
some active antiseptic, such as mercuric chlorid or 
dilute iodin (one part tincture of iodin in nine parts of 
water) should be applied. Under no circumstances 
should any dressing be allowed to remain on a vaccina- 
tion wound longer than twenty-four hours, and no 
dressing should be applied so long as the natural pro- 
tection is intact. 

On account of possible fouling by perspiration and 
to lessen the chance of exposure to street dust, pri- 
mary vaccination should be performed preferably in 
cool weather. In order to encourage proper surgical 
treatment, no charge should be made for the after-care 
of a vaccination, or for revaccination in case the first 
attempt should prove unsuccessful. 

Although apparently trivial, vaccination is an opera- 
tion which demands skill in performance and care in 



TRANSFUSION OF BLOOD 719 

after-treatment in order to avoid the rare, but serious, 
complications. For the prevention of these complica- 
tions vaccination (a) should be performed with strictly 
aseptic technic, {b) should cover the smallest possible 
area for each insertion, and (c) should be treated with- 
out any covering which permits maceration. 

A child should be vaccinated by the time it has 
reached the age of 6 months, and the operation should 
be repeated at about 6 years of age and whenever an 
epidemic of smallpox is present. 

TRANSFUSION OF BLOOD 

The idea of introducing healthy blood into the circu- 
lation of a person threatened with death either from 
chronic disease or from some acute accident is not a 
new one. As far back as 1667 Denis conceived the 
idea of blood transfer and used it successfully in a 
human being. Early it became evident that there were 
certain objections to the introduction of the blood of 
lower animals into man, and the practice fell into 
disuse. During the last century experiments were 
made on the direct transference of blood from one 
person to another. This was attempted by means of 
rather complicated apparatus and under certain handi- 
caps which now may be avoided. The earlier attempts 
of this sort were made before the days of perfect 
aseptic technic, and infection sometimes followed the 
operation of transfusion. Recently, because of an 
increased interest in the possibilities of transfusion, 
there have been published descriptions and results of 
several new methods. These methods tend to the 
elimination of those factors that are responsible for 
untoward symptoms following transfusion. With a 
knowledge of the processes concerned in coagulation, 
and also with the perfection of simple and reliable 
methods for testing the properties of the blood plasma 
and red blood corpuscles, unfavorable results, due 
to the infusion of the blood itself, are uncommon. 
Transfusion in the hands of a trained and expe- 
rienced operator is fraught with little or no danger to 
either the donor or the recipient of the blood. This 
fact has led investigators to experiment on many 
different types of disease in which previously it would 
not have been deemed advisable to transfuse. 



720 TRANSFUSION OF BLOOD 

When transfusions were first attempted, and even 
up to recent years,' little thought was given to the 
possibility of severe reactions or symptoms. These do 
not occur in more than 10 per cent, of the transfused 
cases. Some of these are trivial and do not last long ; 
others, however, may be of a serious nature. Some of 
the symptoms resemble those seen in serum sickness, 
with a rise in temperature, chills, and the appearance 
of an urticarial rash. Others are of an anaphylactic 
character, accompanied by shock. However, with 
properly conducted tests, it may be stated that there 
need be no fatal cases traceable to the transfusion 
itself. 

Whatever untoward symptoms or fatal cases occur 
as a result of the transfusion may be traced to some 
disturbing element in the introduced blood ; to the for- 
mation of a thrombus; to the introduction of an 
embolus, or to the dilation of an already weakened 
heart by too large an injection of blood or by a too 
great pressure exerted in the introduction of the blood. 
The introduced blood may have the property of agglu- 
tinating or hemolyzing the blood of the patient. 
Recently, Satterlee and Hooker have suggested three 
possibilities: (1) a disturbed trypsin-antitrypsin bal- 
ance in the recipient's blood resulting in the formation 
of a serotoxin; (2) the disturbance of the protective 
colloids in the body cells of the recipient, exposing 
them to a reaction of antigen and antibody in the cir- 
culation of the recipient, and (3) a toxic disturbance 
resulting from incipient coagulative changes produced 
by physical influences arising during the process of the 
transfusion (Jour. A. M. A., Feb. 26, 1916, p. 618). 

Agglutination and hemolysis can be avoided by pre- 
liminary tests, mixing the donor's corpuscles with the 
receptor's serum and vice versa. Infusion of syphilitic 
blood must be prevented by a complement-fixation test 
of the blood of the donor. The problem of eliminating 
any other disturbing factors in the blood is still one to 
be investigated. Although several anticoagulants have 
been suggested for the prevention of coagulation, so 
far only two have been advocated, herudin (an extract 
of leech) and sodium citrate, and of these the sodium 
citrate has been shown to be the safer and more 
reliable. It has been found that herudin preparations,. 



METHODS OF BLOOD TRANSFUSION 721 

particularly those which have been prepared for some 
time, undergo a certain amount of chemical change 
with the production of a toxic substance. Sodium 
citrate, on the other hand, has been used very success- 
fully with no, or but very few, untoward effects. 

METHODS 

Transfusion methods may be divided into two kinds, 
the direct and the indirect. By the direct methods 
are meant those in which the artery of the donor and 
the vein of the recipient, or the veins of each, are 
brought into contact either by being sutured or by 
being connected with a tube or with a cannula. Car- 
rell was perhaps the first to suture the vessels together, 
and although this method has been successful in some 
cases, nevertheless it has the disadvantage that it is too 
time-consuming, and that the amount of blood passing 
from donor to recipient cannot be measured. This can 
also be said of most direct methods. Time is con- 
sumed in dissecting out sufficient lengths of the ves- 
sels so that they can be easily handled. For the pur- 
pose of preventing clotting of blood during its passage, 
when the cannula or straight tube is used, these are 
treated with sterile paraffin or albolene. These sub- 
stances work admirably. 

The cannula method described by Crile is typical 
of other cannula methods. He uses a cannula through 
which he draws the proximal end of the divided vein 
and then turns back the end of the vein like a cuff over 
the end of the cannula. Over this he then draws the 
proximal end of the divided artery. The radial artery 
of the donor and the median basilic or cephalic of the 
recipient are used. This is rendered comparatively 
easy by having the patients lie beside each other, but 
with their feet in opposite directions. This operation 
brings into contact the intima of the artery with the 
intima of the vein and this greatly minimizes the 
liability to clotting of the blood. 

Transfusion by means of a connecting tube is 
described by Vincent. This consists in the use of 
glass tubes which are used to connect the vein of the 
recipient with the artery of the donor. These tubes 



722 METHODS OF BLOOD TRANSFUSION 

are usually from 3 to 8 cm. in length. In order to 
avoid clotting, the tubes are coated with various prepa- 
rations, such as liquid petroleum, petrolatum, stearin 
or paraffin. It was found that petrolatum made too 
soft a covering, and stearin too hard and rough a 
covering. A mixture of petrolatum, paraffin and stearin 
in 2:2:1 proportions gives the smoothest and a 
sufficiently hard covering. It was also found that the 
blood ran very well in plain glass tubes, so that they 
might be used with a fair chance of success if it were 
not practicable to use the coated tubes. (Am. Jour. 
Dis. Child., May, 1911, p. 376.) 

Probably the first indirect method was the use of 
defibrinated blood, the fibrin having been removed 
after whipping up the blood. This method, on account 
of the possibility of infection and red blood and plate- 
let destruction, was given up. In 1913, Lindeman 
announced a simple method of transfusion which did 
not necessitate cutting down on and dissecting out the 
vessels of the donor and recipient. Other advantages 
of the method were that it could be carried out rapidly, 
and that the amount of blood used could be accurately 
measured. Lindeman's method consists of the use of 
several record syringes, each with a capacity of 20 c.c. 
Two operators are required, and special cannulas are 
used. After the donor and recipient have been placed 
in recumbent positions, the veins to be used are 
selected. As a rule the median basilic is the vein of. 
choice. In infants the external jugular is better on 
account of its large size and easy accessibility. A 
tourniquet is placed around the arm of the recipient, 
the skin sterilized, and the cannula inserted into the 
vein. The tourniquet is removed, and to avoid escape 
of blood, a syringe filled with sterile saline solution is 
attached to the cannula until ready for use. The arm 
of the donor is treated in a similar manner, with the 
tourniquet above the site of puncture. After this has 
been done, the syringes are rapidly filled with blood 
from the donor's vein and injected through the can- 
nula into the vein of the recipient. To prevent clotting, 
after each injection of blood a little sterile saline solu- 
tion is injected into the cannula in the recipient's vein. 
Before a syringe is used a second time, it must be 
cleansed with sterile water. Dexterity and speed are 



ANTICOAGULANTS 723 

necessary. Other advantages in this method are that 
both arms of the donor can be used at the same time, 
and that there is no permanent injury to the blood ves- 
sels. The same vein can be used repeatedly for other 
transfusions. In 155 cases in which a total of 
136,800 c.c. of blood was transfused, there was not one 
death referable to the transfusion. The adults 
received from 1,000 to 1,800 c.c. at each transfusion. 

The Lindeman method, however, was open to several 
objections. These were the constant connecting and 
disconnecting of the syringe, namely, inability to gage 
the force with which the blood was injected each time 
and the risk of clotting, inasmuch as the blood was 
exposed to the air when the syringes were disconnected. 
It also required the services of two operators both 
expert in the handling of the syringes. 

To obviate these objectionable features, Unger 
(Jour. A. M. A., Feb, 13, 1915, p. 582) devised 
an apparatus with a central stopcock arrangement, 
the stopcock of which could be arranged so that 
the blood drawn out from the vein of the donor with 
a 20 c.c. syringe could be injected into the vein of the 
recipient with the same syringe. Needles or cannulas 
are inserted into the veins of both donor and recipient 
as in the Lindeman method, and these are connected 
with the apparatus. Only one syringe is required for 
this, and at no time is the blood exposed to the air. 
Another feature of the apparatus is that the passages 
traversed by the blood can be kept clean by flushing 
them occasionally with sterile saline solution by means 
of another syringe attachment. Very good results 
without secondary symptoms have been reported with 
Unger's apparatus. A similar shuttle apparatus was 
designed by Miller of Brooklyn. In fact, the various 
types of blood transfusion apparatus all have com- 
mendable and condemnable features. Any good instru- 
ment house can display four or five types among which 
the physician may make a choice. 

ANTICOAGULANTS 

A somewhgt different method of indirect transfusion 
is the use of blood to which has been added an anti- 
coagulant. It has already been mentioned that the anti- 



724 TECHNIC OF BLOOD TRANSFUSION 

coagulants which have proved most successful are 
herudin and sodium citrate. Herudin, however, under 
certain conditions develops toxic properties which 
should exclude it for transfusion purposes. Sodium 
citrate has proved very favorable, and has some good 
features to commend it. One of these features is that 
blood may be drawn from a donor into the citrate 
solution and carried to another place for use. It may 
be kept on ice for a week and used. It does away 
with the usual operating room technic, and may be 
injected into the vein of a patient at his home. 

Hustin in 1914 reported the result of a transfusion 
in a human being in which the blood was kept fluid 
by means of 0.2 per cent, sodium citrate and mixed 
with an equal amount of physiologic sodium chlorid 
solution containing glucose before injection. Weil in 
1914 stated that he had successfully transfused human 
beings with as much as 250 c.c. of blood kept fluid 
by means of sodium citrate. Lewisohn shortly aftes 
described the use of 0.2 per cent, sodium citrate solu- 
tion for this purpose and this has proved to be the 
most satisfactory method. 

TECHNIC 

Sydenstricker, Mason and Rivers have described 
their technic at the Johns Hopkins Hospital {Jour. 
A. M. A., June 9, 1917, p. 1677) in some detail. The 
blood of the donor having previously been tested for 
agglutination and hemolysis with the blood of the 
recipient, also with the Wassermann test, his arm is 
cleaned and prepared as though for the injection of 
salvarsan and the needle is inserted into the vein. 
The needle is connected by a short length of pure gum 
rubber tubing, previously sterilized, to a right angled 
glass tubing which is inserted through a rubber stop- 
per in a wide mouthed bottle of some 250 to 1,000 c.c. 
capacity. Through another hole in the bottle another 
piece of right angled tubing is placed to which is 
attached a rubber tubing for gentle suction should the 
needle become clogged. Finally through another cen- 
tral hole in the stopper is placed an ordinary sepa- 
rating glass funnel. It is, of course, understood that 
all of the apparatus is sterilized. It is also previously 



TECHNIC OF BLOOD TRANSFUSION 725 

rinsed with sterile normal salt solution. Five c.c. of 
25 per cent, sodium citrate solution are allowed to run 
into the bottle through the separating funnel. The 
needle is inserted in the vein and the blood allowed 
to run freely into the bottle. As the blood flows in 
the cock of the funnel is opened wide enough to allow 
citrate solution to drip in at the rate of 10 c.c. for 
each 90 c.c. of blood. The bottle may, meanwhile, 
be gently agitated. The blood is then transferred 
directly to a sterile salvarsan apparatus and allowed 
to run into the median basilic vein of the recipient 
as in salvarsan injections. After 25 c.c. have been 
introduced it is well to wait to see that no reaction 
occurs. 

Lewisohn's technic is more simple. He divides his 
description into two parts: 

1. Obtaining the blood from the donor: A tourni- 
quet is applied to the donor's arm, and one of the 
larger veins in the elbow region (usually the median 
cephalic vein) is punctured. A cannula of large diame- 
ter is used in order that the blood may flow out rapidly 
through the needle. The blood is collected in a gradu- 
ated glass jar which contains at its bottom the 2 per 
cent, citrate solution. If we want to give 450 c.c. of 
blood, we add 50 c.c. of this solution, thus effecting 
a 2 per thousand mixture. Smaller and larger amounts 
of blood are treated proportionately. It is important 
to take good care that in mixing blood and citrate the 
proportion is never less than 2 per thousand. In order 
to prevent such an occurrence it might be advisable to 
add a few cubic centimeters of surplus citrate solution 
which can be done with perfect safety. 

2. Infusion of the blood into the recipient. The 
recipient is usually so anemic that we have to expose 
the vein by a small incision in about 80 per cent, of the 
cases. The cannula is inserted, and the latter is 
attached to a salvarsan apparatus which contains from 
20 to 30 c.c. of physiologic sodium chlorid solution. 
The blood is then poured into this apparatus and 
allowed to run into the punctured vein by gravitation 
(exactly like an ordinary saline infusion). 



726 DOSAGE OF BLOOD TRANSFUSION 
» DOSAGE 

As recently pointed out by Unger {Jour. A. M. A. 
73:815, 1919), with blood, as with other therapeutic 
measures, the amount given is a factor in determining 
the result. A donor can with safety supply one quarter 
of his blood volume. Just how much of this a patient 
should be given is dependent on various factors. For 
infants the usual dose should be from 80 to 150 c.c. 
For adults, from 800 to 1,000 c.c. This amount, of 
course, varies with the weight, the condition of the 
patient's heart and lungs, and the disease for which the 
transfusion is being performed. 

Overtransfusion from the donor's standpoint is evi- 
denced by an increase of the pulse and respiratory 
rates, repeated yawning. or deep sighing. Changes in 
the rhythm of respiration may occur before a change 
of the pulse rate. If these symptoms appear, the 
transfusion should be discontinued. Pallor and sweat- 
ing are occasionally followed by collapse. From these 
symptoms he will quickly recover if the transfusion 
is discontinued. 

As regards the patient, hypertransfusion is more 
serious. This may lead him to complain of precordial 
distress, headache, backache, or pain in his legs. A 
more important sign, however, is a short, sharp cough. 
If the transfusion is continued, the cough will be 
repeated. The cough, when it does appear, occurs 
irrespective of the rate at which the blood was trans- 
fused. Unger emphasizes particularly that one should 
not transfuse more than 200 c.c. after the first cough. 

INDICATIONS 

As technic improves and experience increases in 
transfusions, more and more indications for its use are 
being found. It is no longer used only as a last resort 
for life-saving purposes. It is rinding its field of use- 
fulness extended to diseases in which an influx of some 
new blood might hasten the progress toward improve- 
ment, or diseases in which it will tide the patient over 
a temporary relapse. In reviewing the results of 212 
blood transfusions in 189 cases, Ottenberg and Lib- 
man (Am. Jour. Med. Sc, 1915, 150, 36) mention a 



DOSAGE OF BLOOD TRANSFUSION 727 

large number of varied conditions in which transfusion 
was tried. They also discuss the results obtained in 
each condition. Their classification is as follows : 

I. Transfusions for simple hemorrhage. 

1. Gastric and duodenal ulcer. 

2. Dysentery. 

3. Typhoid hemorrhage. 

4. Ectopic pregnancy. 

II. Transfusions in connection with surgical operations. 

1. Preliminary to operation. 

2. For postoperative hemorrhage. 

3. For shock. 

III. Transfusions for the cure of hemorrhagic conditions. 

1. Purpura hemorrhagica. 

2. Hemophilia. 

3. 'Hemorrhages secondary to: 
(a) Blood diseases. 
(&) Severe infections. 
(c) Jaundice (cholemia). 

IV. Transfusions for blood diseases. 

1. Pernicious anemia. 

2. Leukemia. 

V. Transfusions for infections. 

1. Infections with pyogenic organisms. 

2. Subacute streptococcus endocarditis. 

VI. Transfusions for intoxications. 

1. Acute poisoning. 

2. Diabetic coma. 

VII. Transfusions for debilitated conditions. 

1. Cancer. 

2. Malnutrition. 

3. Simple anemia. 

The experience of Ottenberg and Libman in the 
foregoing cases was as follows : 

In duodenal or gastric ulcer the hemorrhage was 
stopped in twelve of fourteen cases in which the con- 
ditions were desperate. The cases best adapted are 
those in which there has been repeated or prolonged 
bleeding. In acutely bleeding cases there is danger of 
increasing the hemorrhage through increase in blood 
pressure. 

The dysentery cases were not so successful as to 
their final outcome. In four of six cases transfused, 
the patients died from a continuation of the dysentery. 



728 DOSAGE OF BLOOD TRANSFUSION 

In typhoid fever, in which nine transfusions had 
been performed in seven cases, two of the patients 
ultimately recovered. They state that "in all typhoid 
cases, the first appearance of blood in the stools should 
be an indication to make preparations so that transfu- 
sion can be done, if needed, at very short notice." 

In bleeding in ectopic pregnancy, transfusion was 
life-saving in all of three cases transfused. 

In transfusions done in connection with surgical 
operations, in thirty-three preoperative transfusions, 
thirteen patients recovered from the operation. Some 
of the others died from postoperative complications. 
They had three brilliant recoveries in five transfusions 
for postoperative hemorrhage. In shock, however, 
transfusion was disappointing. 

With the hemorrhagic conditions, in nine cases of 
purpura hemorrhagica, six patients recovered com- 
pletely. In hemophilia, in five out of six cases the 
hemorrhage ceased and the patients regained good 
health. In hemorrhage secondary to infection, in one, 
a case of a new-born, the hemorrhages were checked. 
In another with gonorrheal rheumatism, transfusion 
was followed by recovery, while in a third case of 
hemorrhagic diphtheria, the patient died. 

In three cases of acute leukemia, the hemorrhages 
did not cease after transfusion, whereas in one chronic 
case it. did. 

Transfusions for hemorrhage in jaundice have been 
very disappointing, the hemorrhage persisting after- 
ward, even in the nonmalignant cases. 

The experience of Ottenberg and Libman with trans- 
fusions in pernicious anemia consisted of thirty-five 
transfusions in twenty-five cases. In no case was 
there a cure; in eleven cases no effect was observed, 
whereas in fourteen cases immediately following the 
transfusion, there were more or less prolonged remis- 
sions. They quote one case in which splenectomy was 
also done after the third transfusion, with a brilliant 
result, the patient returning to excellent health. In 
their summary they state that although transfusion 
never cures pernicious anemia, nevertheless it is the 
best remedy, for it leads to remissions in about half 
the cases. 



DOSAGE OF BLOOD TRANSFUSION 729 

In leukemia, the transfusion was performed in ten 
cases. In the acute cases, the patients did not fare 
well, whereas in the chronic cases of the lymphatic 
type there was a tendency for the blood picture to 
return to normal. This, however, was only tempo- 
rary, as the leukemic blood picture ultimately returned. 

Transfusions were also done in infectious diseases. 
It was done only as a last resort in some of the very 
desperate cases. There were ten cases, and four of 
these patients recovered. Three of these successful 
cases were osteomyelitic infections due to Staphylo- 
coccus aureus. The fourth case was a streptococcic 
infection. 

In endocarditis, transfusing was resorted to to com- 
bat the anemia. There were four cases, all due to the 
Streptococcus viridans. In three of these cases there 
was temporary improvement, but all four patients suc- 
cumbed to the disease. 

Transfusion is of value in cases of poisoning due to 
carbon monoxid, hydrocyanic acid, benzene or nitro- 
benzene when the blood has been acted on by these to 
a marked degree. Preliminary phlebotomy, however, 
is very essential. 

Diabetic coma offers a poor field for transfusion. 
In four cases in which transfusion was performed, not 
one patient recovered. 

In debilitated conditions caused by cancer, transfu- 
sion without surgical interference is of no avail. On 
the other hand, it may relieve the anemia in tubercu- 
losis. In the simple anemias due to malnutrition or 
other minor causes, transfusion is justified, and satis- 
factory results can be obtained. 

In a series of fifteen cases of hemorrhagic disease of 
the new-born, Lespinasse transfused by the direct 
method, and obtained recoveries in thirteen. 

More recently Unger {Jour. A. M. A., Dec. 29, 
1917, p. 2160) has published the results in 165 cases 
of blood transfusion. The indications for transfusion 
he states to be (1) hemorrhage; (2) diseases of the 
blood; (3) toxemias; (4) infections; (5) shock, and 
(6) general debility. The diseases in which hemor- 
rhage was the indication are grouped: (a) gastric or 
duodenal ulcer; (b) typhoid fever; (c) postoperative 



730 INDICATIONS FOR BLOOD TRANSFUSION 

hemorrhage; (d) ectopic gestation; (e) uterine hemor- 
rhage; (/) ulcerative colitis ; (g) jaundice; (h) hemor- 
rhage associated with blood diseases, and (i) miscel- 
laneous cases, including hematemeses of unknown 
origin, intestinal hemorrhage of unknown origin and 
bleeding from multiple telangiectases. Sixty-two trans- 
fusions were done in forty-seven cases in this group. 
In fifteen of these cases the transfusion was undoubt- 
edly a life-saving procedure. 

The diseases of the blood include (a) secondary 
anemia; (b) pernicious anemia; (c) hemophilia; (d) 
purpura hemorrhagica; (e) leukemia; (/) bleeding of 
the new-born, and (g) miscellaneous, including Banti's 
disease, von Jaksch's anemia and Henoch's purpura. 
He concludes that transfusion is of value and to be 
recommended in pernicious anemia but can be expected 
to produce remissions in only about half of the cases. 
In hemophilia it can be relied on to stop the hemor- 
rhage, but in no way to affect the course of the dis- 
ease. In purpura it is much less reliable; in fact, 
recovery followed in only two of our six patients. In 
acute leukemia it is of but temporary benefit. In 
bleeding of the new-born it is a specific and essentially 
a life-saving measure. 

Transfusion was done with toxemia as the indication 
in (a) pneumonia; (b) pyogenic infections ; (c) illum- 
inating gas poisoning; (d) morphin poisoning; (e) 
uremia; (/) scurvy, and (g) toxemia of pregnancy. 

As a result of this varied experience Unger con- 
cludes : 

"The best results of transfusion were obtained in 
hemorrhage, diseases of the blood, toxemias and shock. 
In 88 per* cent, of the cases of acute hemorrhage, 
bleeding was stopped by one transfusion. In per- 
nicious anemia, remissions can be initiated. Repeated 
transfusions frequently bring on repeated remissions. 
If no remission results, transfusion with a different 
donor should be performed. For the hemorrhage of 
hemophilia, transfusion is practically a specific. It is 
dangerous to delay too long with palliative measures if 
active bleeding is present. In purpura, transfusion 
gives only moderately good results. In the severe cases, 
it would seem advisable to carry out the suggestion 



REACTIONS TO BLOOD TRANSFUSION 731 

of splenectomy with preliminary transfusions. All 
attempts to influence acute leukemia failed. In bleed- 
ing of the new-born, transfusion is a specific. Espe- 
cially in cases of melena, temporizing by using other 
methods is contraindicated. The median basilic vein 
can be used regardless of the baby's age, and is the 
route of choice. 

"Transfusion, although employed in a comparatively 
small number of cases, has yielded encouraging results 
in toxemia associated with acute infections (e. g., pneu- 
monia), toxemia of pregnancy, scurvy and shock. It 
seems to overcome shock if employed at the onset of 
the symptoms. 

"Transfusion is often of assistance in overcoming 
intractable suppurative processes and causing a marked 
increase in the vitality of the patient. In bacteremias, 
it has had practically no success. It is possible, how- 
ever, that if immune donors were used the results 
might be better. Transfusion given preliminary to 
an operation will often so improve the patient's con- 
dition that the surgeon is justified in risking an opera- 
tion. It will prolong the life of a patient suffering 
with a debilitating condition. 

"The syringe cannula method (requiring only one 
syringe) has proved a simple, efficient and dependable 
one for giving whole unmodified blood. The giving 
of unmodified blood is the method of choice when 
blood is required as a tissue (as in various anemias). 
When it is required to replenish impoverished circu- 
lation, citrated blood can serve as a substitute." 

In a final report on his work, Lindeman (Jour. 
A. M. A. 73:896, 1919) has defined certain critical 
periods in disease when blood transfusion is especially 
important. In long standing cases of sepsis, in per- 
nicious anemia, in tropical sprue, in gas poisoning, in 
nephritis with severe anemia, in leprosy, in aleukemic 
leukemia and following hemorrhage, blood transfusion 
may act specifically as a life saving factor in thera- 
peutics. 

REACTIONS TO TRANSFUSION 

It has been shown by De Kreuf that blood acquires 
toxic properties in direct proportion to the path it has 
traveled toward coagulation. Pemberton (Surg., 



732 REACTIONS TO BLOOD TRANSFUSION 

Gynec. Obstet. 28:262, 1918) has described a typical 
reaction following transfusion of incompatible blood : 

The patient first complains of tingling pains shoot- 
ing over the body, a fulness in the head and an oppres- 
sive feeling about the precordium, and, later, an 
excruciating pain localized in the lumbar region. 
Slowly but perceptibly the face becomes suffused, a 
dark red to a cyanotic hue ; respirations become some- 
what labored, and the pulse rate, at first slow, some- 
times suddenly drops as many as 20 to 30 beats a 
minute. The patient may lose consciousness for a few 
minutes. In one half of our cases an urticarial erup- 
tion, generalized over the body, or limited to the face, 
appeared along with these symptoms. Later the pulse 
may become very rapid and thready; the skin becomes 
cold and clammy, and the patient's condition is indeed 
grave. In from fifteen minutes to an hour, a chill 
occurs, followed by high fever, a temperature of 103 to 
105 degrees, in which the patient may become delirious. 
Jaundice may appear later. The macroscopic appear- 
ance of hemoglobinuria is almost constant. 

Pemberton concludes that these cases "point out most 
strikingly the fact that the injection of incompatible 
blood, namely, blood in which the donor's cells are 
agglutinable by the serum of the patient, is attended by 
the development of symptoms of the gravest nature, 
and that if these are not early recognized and the trans- 
fusion concluded before the injection of a large 
quantity of blood, fatal results are to be expected." 

In the case of citrate transfusions, certain special 
untoward factors concerned have been made the sub- 
ject of study in man by Drinker and Brittingham 
(Arch. Int. Med. 23: 133, 1919) at the Harvard Medi- 
cal School laboratories. They have failed to observe 
any constant relation between the method of citration 
or the purity of the citrate used and the number of reac- 
tions. The objectionable component resides in the cells 
of the blood; for citrated plasma, thoroughly freed 
from all formed elements by prolonged high speed 
centrifugalization or by porcelain filtration, is singu- 
larly nontoxic, contrasting markedly with serum in this 
regard. On the other hand, the washed whole cell 
content of blood is uniformly toxic, whether injected 



REACTIONS TO BLOOD TRANSFUSION 733 

into the individual from whom the cells have been 
removed (plasmapheresis) or into different individuals 
who have been tested and show no agglutination or 
hemolysis of red cells. 

A further analysis of the location of the factors in 
the cells responsible for the difficulties indicates that 
reactions decrease as the platelets are removed from 
the transfusion mixture. The Harvard investigators 
report that salt solution, red cells, white cells in greatly 
reduced numbers, and absence of platelets make the 
most perfect blood for transfusion that they have 
observed. 

Transfusion is a comparatively easy and safe pro- 
cedure; it is a scientific method of treatment in a 
variety of conditions and its field of usefulness may be 
considerably extended. 



INDEX TO SUBJECTS 



PAGE 

Abbreviations, Latin, used in prescription writing 27 

Abortion, therapeutic 624 

Acetanilid in pneumonia. . . 168 

Acetone, tests for acetone and diacetic acid in urine 668 

Acidity, to lessen , 35 

Acidosis, alkali therapy in 350 

in children 667 

in diabetes 347 

symptoms of '. 668 

treatment of 669, 351 

Acne, boric acid in . 578 

Adhesive plaster treatment of burns 572 

Albuminized milk 69 1 

Albuminous drinks 691 

Albuminuria 323 

treatment of 324 

Alcohol, prescribing 26 

Alcoholism: see Delirium tremens. 

Alkali therapy in acidosis 350 

Allen treatment of diabetes 339 

Allergy: see Anaphylaxis 

Aloes, pills of 16 

Alopecia 547 

Alveolar air 349 

Ammoniacal diapers 670 

Ammonium chlorid in pneumonia 168 

Analgesics for pain arid itchings 34 

Anaphylaxis 703 

calcium in 710 

definition of 706 

manifestation of 707 

treatment of 709 

vaccine treatment of 705 

Anemia 403 

diet in 403 

pernicious 405 

pernicious, arsenic in 406 

pernicious, blood transfusion in 406 

pernicious, splenectomy in 406 

pernicious, treatment of . 407 

treatment of 403 

Anesthesia 693 

bladder and kidneys in 696 

ether, contraindications of 699 

lung complications in 697 

nausea and vomiting in 696 

safe, essentials of 693 

salines in 697 

Anesthetics, local 34 

Anesthetist, duties of 694 

Angina pectoris 394 

immediate treatment of 394 

prevention of 395 

symptoms of 394 

Anodynes and analgesics, local, for pain and itchings 34 

Anthelmintics 35 



736 INDEX 

PAGE 

Antipyrin in pneumonia 168 

Antiseptics and disinfectants 34 

Aortic insufficiency 386 

stenosis 383 

Arrowroot gruel 688 

Arsenic in pernicious anemia 406 

in psoriasis 541 

in tuberculosis 203 

Arsphenamin and neoarsphenamin^ in syphilis 585 

injection of 586 

toxicity of 587 

Arthritis, chronic 175 

chronic, medicinal treatment of 177 

chronic, nonspecific protein injections in 177 

chronic, treatment of 175 

chronic, vaccines in 176 

deformans 178 

tuberculous 220 

Ascaris lumbricoides 317 

Ascaris lumbricoides, treatment of 318 

Asphyxia 497 

artificial respiration in 642 

livida 641 

neonatorum 640 

neonatorum, prevention of 641 

pallida 644 

Asthma 237 

and tuberculosis 222 

causes of 237 

drugs in 241 

general treatment of 239 

inhalations for 245 

paroxysms of 243 

paroxysms of, treatment of 243 

protein immunization in 246 

sensitization in 240 

symptomatology of 238 

Astringents .- 34 

in gonorrhea 602 

Auricular fibrillation 396 

incidence of , 397 

treatment of 398 

Backache 454 

definition of 455 

due to abdominal conditions 463 

due to infection 458 

due to inflammation of nerves 457 

due to pelvic conditions 462 

due to strain or lack of balance 456 

etiology of 455 

Baldness, causes of 548 

prevention of ; 551 

treatment of 552 

Barley gruel 688 

gruel with broth 688 

water 690 

Baths and massage in chronic nephritis 332 

cabinet 684 

continuous 684 

sitz 685 

Benzol in leukemia 410 

Bitters 35 



INDEX 737 

PAGE 

Bladder and kidneys in anesthesia 696 

Blaud's pills 16 

Blepharitis 509 

Blood and blood-making organs, disturbances of 403 

drugs used for their effects on 37 

pressure . ., 364 

pressure, high 364 

pressure, high, drugs in 369 

pressure, high, etiology of 365 

pressure, high, cardiovascular renal 332 

pressure, high, prevention of 366 

pressure, high, treatment of 368 

transfusion 719 

transfusion and anticoagulation 723 

transfusion, dosage in 726 

transfusion in anemia 406 

transfusion, indications for 726 

transfusion, methods of 721 

transfusion, reactions to 73 1 

transfusion, teohnic of 724 

Boils and carbuncles 543 

etiology of 543 

treatment of 544 

Bone tuberculosis 216 

Boric acid in acne 578 

in furuncle 578 

in impetigo 579 

in paronychia 581 

in perleche 580 

in skin diseases 578 

in styes 578 

Botulism 180 

prophylaxis ^_ 180 

symptoms of 181 

treatment of 181 

Brachial neuritis 45 1 

Bran bread 692 

Bread, bran . . ." 692 

Breast feeding 647 

contraindications 651 

lack of milk in breast feeding 650 

technic in 648 

Breath, foul 261 

Bromides in epilepsy 440 

Bronchitis, acute 235 

treatment of 236 

Burns 570 

adhesive plaster treatment of 572 

general treatment of 573 

of eye from lime 514 

paraffin treatment of 572 

. treatment of 572 

Caffein in pneumonia 170 

Calcium in anaphylaxis 710 

Camphor in pneumonia 169 

Capsules, use of 32 

Carbuncles ■ 545 

and boils • 543 

treatment of 546 

Cardiovascular renal disease with high blood pressure 332 

Carminatives 35 

Caustics or corrosives 34 



738 INDEX 

PAGE 

Cerebral edema in delirium tremens 485 

Cervical glands, tuberculosis of 215 

Chancroid 609 

Chapped handsl 559 

Chemotherapy of tuberculosis 204 

Chenopodium in hookworm disease 313 

Chicken pox 106 

Chilblain 560 

treatment of ■. 561 

Children, acidosis in 667 

convulsions in 662 

diet for 675 

diet for, from five to seven 676 

diet for, from two to seven 673 

incontinence of urine in 677 

nervous 655 

psychogenic disturbances in, special treatment of 661 

sleep in 657 

table of average weight to height at different ages 29 

Chloasma 577 

Chlorid of lime as disinfectant 701 

Chlorosis 403 

treatment in 404 

Cholera 288 

prevention of 288 

treatment of 289 

Chorea 434 

autoserum treatment of 436 

medicinal treatment of 435 

treatment of 434 

Chrysarobin in psoriasis 542 

Codein in pneumonia 168 

Cod-liver oil in tuberculosis , 202 

Colds, bacteriology of 225 

cleansing nasopharynx in 230 ' 

common 225 

prophylaxis of 225 

rhinitis tablets in 228 

sprays for 229, 230 

treatment of 227 

Colic in infants . 649 

Constipation: see also Intestinal stasis 

habit and 305 

laxative foods 305 

massage in 306 

medicinal treatment of 306 

spastic 307 

Convulsions in young children 662 

infantile, treatment of 664 

Copaiba and santal in gonorrhea 598 

Copper sulphate as disinfectant 701 

Corrosive poisoning 41 

Corrosives or caustics 34 

Coughs 232 

causes of 232 

definition of : 232 

in measles 80 

in tuberculosis 206 

types of 233 

Creosote in tuberculosis 201 

Cretinism 429 

Cystinuria 334 



INDEX 739 

PAGE 

Delirium tremens 481 

cerebral edema in 485 

Hogan's treatment in 486 

lumbar puncture in 484 

sedatives in 482 

treatment of active delirium in 483 

Demulcents 35 

Diabetes insipidus 353 

Diabetes mellitus 337 

acidosis in 347 

Allen treatment of 339 

diet in Allen treatment of 341 

duration of fast in Allen treatment of 341 

' preliminary fast in Allen treatment of 340 

complications and sequelae of 352 

definition of 337 

diagnosis! of 338 

exercise in 346 

individualization of diabetic 351 

Joslin's diet table in 342 

object of treatment in 338 

Diacetic acid in urine, tests for 668 

Diapers, ammoniacal 670 

Diarrhea, acute, in infants 671 

in infants 650 

in tuberculosis 212 

Diet in anemia 403 

in anemia 403 

in constipation 304 

in diabetes 341 

in dysentery 283 

in endocarditis 378 

in gonorrhea 596 

in hyperthyroidism 421 

in obesity , 360 

in pellagra 355 

in pneumonia 162 

in psoriasis 542 

in typhoid 139 

in whooping cough 85 

of children from five to seven years 676 

of children from two to four years 675 

Digestion, to promote 35 

Digestives 35 

Digitalis in influenza 154 

in pneumonia 169 

Diphtheria 89 

antitoxin 95 

care of heart in 101 

care of throat in 98 

carriers 89 

carriers, treatment of 90 

general care of patient 95 

general medication in 100 

immunity 92 

immunization with toxin-antitoxin 93 

isolation in 94 

laryngeal 103 

paralysis in 103 

rest after 102 

treatment 94 



740 INDEX 

PAGE 

Disinfectants and antiseptics . 34 

Disinfectant, chlorid of lime as 701 

copper sulphate as 701 

formaldehyd as 701 

liquid 700 

mercuric chlorid as 700 

phenol as 701 

potassium permanganate as 701 

use of, during course of disease 699 

zinc chlorid as 701 

Disinfection 699 

terminal 701 

Dosage 28 

frequency of 30 

Dover's powder 16 

Drinks, albuminous 691 

gruels and starchy drink 687 

Drowning 497 

resuscitation from 498 

Schaf er method of resuscitation 499 

Drug addiction 469 

Jennings' treatment of 475 

Lambert-Towne treatment of 469 

objects of treatment of 468 

Pettey treatment of 472 

Sceleth treatment of 475 

Drugs and preparations which may cause an eruption on, or itching 

of the skin 38 

applied for their local action on skin, wounds or visible mucous 

membranes 34 

classification of 33 

dosage of 28 

hypodermatic or subcutaneous method of giving drugs 32 

incompatibility of 24 

methods of administering 31 

rapidly acting 30 

slowly acting 31 

synonyms 20 

that tend to accumulate in system 31 

used for affections of alimentary tract 35 

used for their effects on circulation 35 

Useful 50 

which are excreted with milk 38 

which cause eruptions. 710 

which color the feces 38 

which may change the color of urine 38 

Duodenum, ulcer of 293 

ulcer of, treatment of 293 

Dysentery, acute 282 

acute, symptoms of 282 

amebic, treatment of 286 

bacillary, treatment of 285 

diet in •. 283 

medicinal treatment of 284 

treatment of 283 

Dysmenorrhea 637 

causes of 638 

treatment of 639 

Dyspnea in tuberculosis 212 

Ear, diseases of 516 

middle-ear inflammations in scarlet fever 74 



INDEX 741 

PAGE 

Eclampsia 624 

complications in 627 

prophylaxis of 625 

treatment of • . . . 626 

Eczema 563 

hyperkeratotic, of palms and soles 568 

picric acid in . .'. 582 

treatment of 564 

Edema, cerebral, in delirium tremens < 485 

Egg broth .691 

Elixirs 18 

Emetics ' 35 

Emmenagogues 36 

Emollients 34 

Emulsions , 18 

Endocarditis 376 

acute, mild 376 

chronic : 380 

diet in 378 

malignant, treatment of 379 

malignant (ulcerative) 378 

symptoms of 377 

treatment of 377 

Endocrine disturbance and neurasthenia 467 

Epilepsy 436 

bromides in 440 

general treatment of 437 

medicinal treatment of , 439 

treatment of 437 

Eruptions, drugs which cause eruptions 710 

Erysipelas 179 

diagnosis of 180 

etiology of 179 

onset and course of 179 

picric acid in 582 

treatment of . i 180 

Ether anesthesia, contraindications of 699 

Evacuation, to promote 35 

Exercise in diabetes 346 

Extracts 16 

Eye, burns of, from lime 514 

diseases of 507 

drugs used locally for their effects on 37 

floating' spots before 514 

in measles 79 

Eyestrain headaches 442 

Family history '. 61 

Feces, chemical examination of 275 

drugs which color 38 

examination of 273 

finding of pathologic ova in 278 

macroscopic examination of 274 

microscopic examination of 274 

pathologic findings 275 

Feet, painful , 453 

sweating of 569 

Fever temperature, drugs to reduce 37 

Fischer treatment of acute nephritis 326 

Floating spots 514 

Flour, browned gruel . 690 

gruel 688 

Fluidextracts 18 



742 INDEX 

PAGE 

Foods, laxative 305 

Formaldehyd as disinfectant 701 

Foul breath 261 

Frostbitt 562 

Furuncle, boric acid in 578 

Gargles and mouth-washes 264 

use of ' 266 

Gas, illuminating, poisoning 490 

Gastro-intestinal tract, diseases of 254 

irritants of 39 

Genito-urinary tract, diseases of 584 

drugs used for their effects on 36 

tuberculosis of 215 

German measles 105 

Glands, cervical, tuberculosis of 215 

Gonorrhea, acute 596 

acute, general treatment of 596 

astringents in 602 

complications of 604 

copaiba and santal in 598 

diet in 596 

irrigations in 60 1 

local treatment in 599 

mercurochrome-220 in 603 

urinary antiseptics in 598 

vaccine and serum therapy of 605 

Gout, etiology of 358 

symptomatology of 358 

treatment of 358 

Grip : see Influenza 147 

Gruels and starchy drinks 687 

Gynecology and obstetrics '....< 618 

Hands, chapped 559 

Harrison Narcotic Law 25 

Hay -fever 247 

general treatment of 250 

pollens in 253 

predisposition to ^ 248 

specific treatment of 252 

Headache 441 

causes of 441 

eye-strain 442 

habit , 443 

treatment of 444 

Heart, aortic insufficiency 386 

aortic stenosis 383 

attack, acute 389 

block 400 

block, treatment of 400 

broken compensation 390 

broken compensation, diet in 390 

broken compensation, treatment of . . 391 

compensated 380 

disease, convalesence in 392 

disturbances of • 364 

disturbances, prevention of 364 

drugs used for their effect on 35 

mitral insufficiency 382 

mitral stenosis 381 

tricuspid insufficiency 387 

tricuspid stenosis . , 388 

valvular disease, chronic 380 



INDEX 743 

PAGE 

Heat exhaustion, treatment of 493 

prostration and sunstroke 492 

Height, table of average weight and, at different ages 29 

Heliotherapy in tuberculosis 204 

Hemophilia (bleeders) 414 

serum in , 417 

symptoms of 415 

tissue extracts in 418 

transfusion in . 419 

treatment of 416 

Hemoptysis in tuberculosis 208 

Hemorrhage, postpartum 635 

postpartum, etiology of 635 

postpartum, treatment of 636 

Herpes labialsis, picric acid in 583 

Hodgkin's disease 411 

blood picture in 412 

treatment of . 412 

Hogan's treatment of delirium tremens 486 

Hookworm disease , 311 

chenopodium in 313 

treatment of 312 

Hordeolum 511 

Hot air, dry, local application of 681 

Hydrotherapy 683 

in obesity 361 

in urology 685 

Hyperacidity 297 

treatment of 299 

Hypertension: see Blood-pressure, high 

Hyperthyroidism 420 

diet in 421 

excitability in 420 

infective foci in 422 

laboratory tests for 420 

rest in 421 

roentgen ray in 422 

specific preparations in 422 

surgery in 423 

symptoms of 420 

thymus in 423 

treatment of 421 

Hypophosphites in tuberculosis 203 

Hyposecretion, signs of 426 

Hypothyroidism (hyposecretion) 424 

in pregnancy 618 

Hypodermatic or subcutaneous method of giving drugs 32 

Illuminating gas poisoning 490 

Impetigo, boric acid in 579 

contagiosa 538 

contagiosa, treatment of . 539 

Incompatibility of drugs 24 

Indian meal gruel 689 

Indieanuria 335 

treatment of 336 

Indigestion 279 

Infancy, diseases of 646 

Infant, breast feeding of 647 

breast feeding of, technic of 648 

colic in 649 

diarrhea in 650, 67 1 

feeding: see also Breast milk 




744 INDEX 

PAGE 

Infant — Continued. 

feeding and mortality 646 

feeding, cow's milk in 653 

influence of posture on digestion in 651 

mortality and feeding 646 

supplementary foods for 652 

weaning of 652 

wet nursing 653 

Infection, focal, and stomach ulcer 291 

Infectious diseases 65 

Influenza 147 

convalescence of 154 

digitalis in 154 

drugs in 153 

etiology of 148 

prophylactic vaccination in 148 

prophylaxis of 149 

serum treatment of 154 

symptomatology of 149 

treatment of 151 

Infusions 18 

Intertrigo, picric acid in 582 

Intestinal ptosis 308 

stasis 304 

stasis, diagnosis of 310 

stasis, diet in 304 

stasis, symptomatology of 309 

stasis, treatment of 310 

Intoxications, acute 468 

Iodids in syphilis 591 

Iodin in tuberculosis 203 

Iritis 511 

treatment of 512 

Itching: see Pruritus 520 

Ivy poisoning 575 

poisoning, treatment of 576 

Jalap powder, compound 16 

Jaundice 301 

diet in 303 

Jennings' treatment of drug addiction 475 

Joint tuberculosis 216 

Joslin's diet table in diabetes 342 

Kendall's preparation of thyroid 432 

Kidney, diseases of 320 

in anesthesia 696 

tuberculosis 322 

Lambert-Towne method for treating drug addiction 469 

Laryngeal diphtheria 103 

tuberculosis 213 

Latin abbreviations 27 

in prescriptions 27 

Laxative foods 305 

Lead-poisoning 478 

symptoms of 479 

Leukemia 409 

benzol in 410 

roentgen-ray treatment "of 410 

treatment of 410 

Licorice powder, compound 16 

Lime burns of eye 514 

Lipovaccines in typhoid 139 

Liquors 17 

Liver, drugs used for their effects on , ; 37 

Lumbago 462 



INDEX 745 

PAGE 

Lumbar puncture in delirium tremens 484 

in tuberculous meningitis 217 

Lung complications in anesthesia 697 

Malaria 186 

organism of 186 

prevention of 186 

quinin in 187 

treatment of 186 

Massage in nephritis 332 

Measles 77 

bowels in 81 

convalescence in 81 

cough in 80 

diet in 81 

eyes in 79 

fever in 81 

German 105 

prophylaxis of 77 

skin in 81 

treatment of 79 

Measures and weights 20 

Meningitis 109 

treatment of Ill 

tuberculous 216 

tuberculous, lumbar puncture in 217 

Menstruation, to promote 36 

Mercuric chlorid as liquid disinfectant 700 

chlorid poisoning 502 

chlorid poisoning, symptoms of 503 

chlorid poisoning, treatment of 503 

Mercurochrome-200 in gonorrhea 603 

Mercury in syphilis 589 

Metabolism, diseases of 337 

Methyl alcohol poisoning, symptoms of 487 

treatment of 489 

Metric system -« 21 

Milk, albuminized 691 

breast, lack of 650 

cow's, in infant feeding 653 

drugs which are excreted with 38 

sterilization and pasteurization 'of 654 

Mitral insufficiency 382 

regurgitations 382 

stenosis .' 381 

Mixtures in prescription writing 18 

Morphin in pneumonia 168 

Mouth, care of, in syphilis 594 

hygiene of 254 

infections 255 

infections, prevention of 258 

infections, treatment of 257 

Mouth-washes and gargles 264 

Mumps 107 

treatment of 108 

Muscae volitantes 514 

Myocardial disturbances '. 373 

Myocarditis, acute 374 

chronic 374 

chronic, treatment of . 375 

Myxedema . . . .' 428 

National Formulary and Pharmacopeia 14 

Nausea and vomiting in anesthesia 696 

Neoarsphenamin in syphilis . , 585 



746 INDEX 

PAGE 

Nephritis, acute 325 

acute, treatment of 327 

chronic 328 

chronic, arteriosclerotic type of 331 

chronic, climate in 333 

chronic, massage and baths 332 

chronic, symptoms of 329 

chronic, treatment of 329 

Fischer treatment of 326 

in scarlet fever 74 

Nervous and circulatory system, depressants of 44 

child 655 

child, treatment of 657 

system, central, irritants of . . . . » 42 

system, central, treatment of poisoning by irritants 43 

system, diseases of 434 

system, drugs used for their effects on central nervous system- • 36 

system, syphilis of 595 

Neuralgia, sciatic neuralgia and sciatic neuritis 446 

Neurasthenia 464 

and endocrine disturbance 467 

causes of 465 

Neuritis, brachial 451 

sciatic neuralgia and sciatic neuritis 446 

New and Nonofficial Remedies 15 

Night-sweats in tuberculosis 211 

Nipples, care of 647 

Nitrobenzene poisoning 489 

Nitroglycerin in pneumonia 170 

Oak poisoning 575 

Oatmeal gruel 689 

water 691 

Obesity 360 

diet in 360 

exercise in 362 

infantile 425 

treatment of 362 

Obstetrics and gynecology 618 

Ophthalmia neonatorum 507 

neonatorum, active treatment of 508 

neonatorum, prophylaxis of . . . 507 

Otitis media 516 

diagnosis of , 517 

treatment of 518 

Oxyuris vermicularis 318 

Pain as a symptom 64 

Paraffin treatment of burns 572 

Paralysis in poliomyelitis 123 

Parasites, to destroy 35 

Paronychia, boric acid in 581 

Parotitis 107 

Patient, family history of 61 

individual tendencies 61 

Pediculosis 573 

Pellagra 354 

diet in 355 

medical treatment of 357 

treatment of 355 

Pericarditis, acute 370 

convalescence in 373 

exudate in 372 

treatment of 370 

Peritonitis, tuberculous 213 

Perleche, boric acid in , , . 580 



INDEX 747 

PAGE 

Pertussis: see Whooping-cough 

Pettey treatment of drug addiction 472 

Pharmacopeia and National Formulary 14 

Pharyngitis, acute • 231 

Phenols as disinfectant 701 

Physical therapy 68 1 

Picric acid in erysipelas 582 

in eczema 582 

in herpes labialis 583 

in intertrigo 582 

in skin diseases 581 

Pills, official 16 

Pin worms 318 

Placenta, retained 631 

Plant poisoning 575 

Pneumonia 155 

abdominal distention in 164 

acetanilid and antipyrin in 168 

ammonium chlorid in 168 

bowels in 1 63 

caffein in 170 

camphor in 169 

care of the skin and mouth in 164 

carriers of 159 

definition of 155 

diet in 162 

digitalis in 169 

etiology of 156 

fresh air treatment of 161 

general considerations of 157 

hypnotics in 1 70 

infecting organism in 155 

medicinal treatment 167 

morphin or codein in 168 

nitroglycerin in 170 

prevention of 158 

prophylactic vaccination in 160 

quinin in 171 

serum treatment of 165 

strophanthin in 169 

strychnin, in . 169 

treatment of 161 

venesection in 170 

Pneumothorax in tuberculosis 210 

Poisoning, corrosive, treatment of 41 

due to depressants of nervous and circulatory system 44 

due to irritants of gastro-intestinal canal 39 

due to irritants of central nervous system 42 

due to irritants of central nervous system, treatment of 43 

plant 575 

symptoms of 41 

treatment of 39 

Poisons, table of special symptoms and special treatment of various 

poisons 46 

Poliomyelitis, acute anterior 114 

cerebrospinal fluid in 119 

complications of 130 

contagion of 116 

convalescence of 130 

definition 114 

diagnosis of 121 

early symptoms of 120 

early treatment of 124 



748 INDEX 

PAGE 

Poliomyelitis, acute anterior — Continued. 

epidemiology of 115 

etiologic organism of 118 

fatality of 116 

late treatment in ... . .' 133 

lumbar puncture in 122 

paralysis in 123 

prognosis in 132 

serum treatment in 127 

specific serums in . 128 

Postpartum hemorrhage 635 

Potassium permanganate') as disinfectant 701 

Powders, official 16 

Pregnancy, diet in 624 

hygiene in 623 

hypothyroidism in 618 

in tuberculosis 222 

medical treatment of 623 

nutrition in 622 

rectal examinations in '. 630 

thyroid in 427 

toxemia of 618 

toxemia, treatment of 620 

uterine displacement in 621 

vomiting of 427, 620 

Prescribing, unscientific 62 

Prescription writing 13 

abbreviations used in 27 

Latin in 27 

Primrose poisoning 575 

Proprietaries, prescribing 14 

Prostate hypertrophy, catheterization in 615 

hypertrophy of, chronic 610 

hypertrophy of, prophylaxis of 610 

hypertrophy, operation in 616 

hypertrophy, symptoms of 611 

hypertrophy, treatment of 613 

Prostatitis and seminal vesiculitis 605 

treatment of 607 

Protectives 34 

Protein immunization in asthma 246 

injections in arthritis 177 

poisoning 703 

Pruritus 520 

ani 525 

ani, etiology of 525 

ani, local remedies in 528 

ani, management of 527 

local applications in 522 

management of 521 

vulvae 529 

Psoriasis 540 

diet in 542 

treatment of 540 

Psychogenic disturbances in children, special treatment of 661 

Psychotherapy 13 

Ptosis, intestinal 308 

Puerperal infection 628 

prevention of 629 

treatment of 632 

uterine hemorrhage in 634 

Puerperium, streptococcal infection in 632 

Pulmonary insufficiency 388 

stenosis 388 

Purgatives, mercurial 35 

saline 35 

vegetable 35 

Purpura hemorrhagica 413 

treatment o£ 414 



INDEX 749 

PAGE 

Pyelitis 320 

treatment of 321 

Pyorrhea alveolaris 259 

treatment of 260 

Quinin in malaria 187 

in pneumonia 171 

Rectal examinations in pregnancy 630 

Respiration, artificial, in asphyxia 642 

Respiratory tract, diseases of 224 

drugs used for their effects on 36 

Resuscitation, Schafer method of 499 

Rheumatism 172 

complication of 175 

pain in 173 

treatment of 172 

Rhinitis tablets in colds, use of 228 

Rhubarb pills, compound 16 

Rice gruel 689 

water 690 

Ringworm 532 

ointments in 535 

roentgen ray in 534 

treatment of 533 

Roentgen dermatitis 558 

Round worm 317 

Rubella (German measles) 105 

Sacro-iliac pain ' 460 

Salines in anesthesia 697 

Salivation, to lessen 35 

Salvarsan: see Arsphenamin 

Santal and copaiba in gonorrhea 598 

Scabies 530 

sulphur in 531 

treatment of 531 

Scarborough test diet 273 

Scarlatina : see Scarlet fever 65 

Scarlet fever 65 

care of nose in 72 

care of skin in 72 

contagiousness of 65 

convalescence ' 75 

convalescent serum in 76 

diet in 70 

fever in 72 

glands of neck in 74 

heart in *..... 73 

isolation and disinfection 66 

isolation of patient 58 

isolation in 70 

late complications 74 

middle-ear inflammations in . .- '74 

nephritis in 74 

prophylactic measures of physicians 69 

prophylaxis during convalescence 69 

prophylaxis of 65 

terminal disinfection 68 

treatment 70 

use of vaccines 76 

vaccines in prophylaxis 70 

Sceleth method of treating drug addiction 475 

Schafer method of resuscitation 499 

Sciatic neuralgia and sciatic neuritis 446 

Sciatica, local treatment in 449 

symptoms of 447 

treatment of 448 

Secretion, to increase 35 

Seidlitz powder 16 

Seminal vesiculitis 60* 



750 INDEX 

PAGE 

Srppy treatment of stomach ulcer 295 

Sitz bath 685 

Skin diseases 520 

diseases, boric acid in 578 

diseases, picric acid in 581 

drugs and preparation which may cause an eruption on, or 

itching of, the skin 38 

drugs used for their effects on . 37 

Sleep disturbances, treatment of 660 

habits of 659 

in children 657 

Smallpox, preparation of vaccines against 717 

vaccination against 716 

vaccination, methods of . 717 

vaccination wound 718 

Spirits in prescription writing 17 

Sprains 682 

Starchy drinks and gruels 687 

Stomach 35 

cases, functional 280 

contents, examination of 268, 270 

contents, microscopic examination of 272 

contents, removal of 269 

interprettion of symptoms referable to stomach 278 

rarity of fermentation in 281 

relation of, to other organs m 280 

"sour" ." 281 

ulcer 290 

ulcer, focal infection and 29 1 

ulcer, hemorrhage in 296 

ulcer, operative indications in 297 

ulcer, Sippy treatment of 295 

ulcer, symptoms of 291 

Streptococcal infection in puerperium 632 

Strophanthin in pneumonia 169 

Struma, simple, of thyroid 423 

Strychnin in pneumonia 169 

Styes 511 

boric acid in 578 

Styptics 34 

Sulphur in scabies 531 

Sumach poisoning 575 

Sunstroke and heat prostration 492 

effect of 496 

treatment of 494 

Sweating of feet and axillae 569 

treatment of 570 

Synonyms for drugs 20 

Syrups 19 

Syphilis 584 

' and diseases of genito-urinary tract 584 

arsphenamin and neoarsphenamin in 585 

care of mouth in 594 

care of primary lesion in ... 585 

early treatment of 584 

iodids in 591 

mercury in 589 

of nervous system 595 

Tablets 33 

Tapeworm 316 

Teeth, care of 267 

hygiene of 254 

Test diet, Scarborough 273 

meal 268 

Tetanus 182 

antitoxin treatment of 184 

prevention of 183 

symptoms of 182 



INDEX 751 

PAGE 

Therapeutic principles, some 61 

Therapeutics, meaning of 13 

more than medicine 62 

Thermometric equivalents 20 

Throat, septic sore 104 

Thymus in hyperthyroidism 423 

Thyroid: see also Hyperthyroidism; Hypothyroidism. 

disturbances of 420 

extract, action of 430 

extract, administration of 43 1 

extract, contraindications to administration of 431 

extract, Kendall's preparation of 432 

extract, uses of 425 

extract, unclassified uses of 430 

in pregnancy 427 

simple struma of 423 

Tinctures 17 

Tinea cruris 536 

cruris, treatment of 537 

tonsurans 536 

trichophytina 532 

Toast water 691 

Tonsils, diseased 103 

Tooth powders and other dentifrices 262 

Towne-Lambert method for treating drug addiction 469 

Tricuspid insufficiency 387 

stenosis 388 

Trinitrotoluene poisoning '. . 500 

Tuberculin in tuberculosis 204 

tests in tuberculosis 198 

Tuberculosis 189 

acute miliary 219 

arsenic in 203 

arrested 223 

asthma and 222 

bone and joint 216 

chemotherapy of 204 

cod-liver oil in 202 

cough in 206 

creosote in 201 

diarrhea in 212 

drugs in 201 

dyspnea in 212 

etiology of 189 

fever in ." 205 

fluoroscopic examination of chest in 198 

general medication in treatment of 201 

heliotherapy in 204 

hemoptysis in 208 

hypophosphites in 203 

iodin in 203 

laryngeal 213 

night-sweats in 211 

of cervical glands 215 

of genito-urinary tract 215 

pain in 208 

pneumothorax in 211 

pregnancy in 222 

pretuberculous symptoms of 194 

prognosis in 220 

prophylaxis of 193 

pulmonary, pneumonia type of 212 

renal 322 

symptoms of 197 

tuberculin in 204 

tuberculin tests in 198 

Tuberculous arthritis 220 

meningitis 216 

peritonitis 213 



752 INDEX 

PAGE 

Typhoid fever 134 

colon enemas in 142 

convalescence in 145 

diet , 139 

general measures in 139 

general prophylaxis of 134 

lipovaccines in 139 

medical treatment in 142 

rules for preventing 136 

treatment of 139 

vaccination against 137 

vaccine therapy of 144 

Typhus fever 145 

Ulcer, duodenal 293 

duodenal, treatment of 293 

Sippy treatment of 295 

stomach and duodenum, focal infection in 291 

stomach and duodenum 290 

stomach and duodenum, hemorrhage in 296 

stomach and duodenum, operative indications in 297 

stomach and duodenum, symptoms of 291 

Uncinariasis 311 

Uremia 333 

restlessness in 334 

treatment of . 333 

venesection in 334 

Urinary tract, diseases of ^ 584 

Urine, drugs which may change the color of 38 

incontinence of, in children 677 

incontinence of, treatment of 678 

tests for acetone and diacetic acid in 668 

to render the urine aseptic 36 

to render the urine less acid . .' 36 

Urology, hydrotherapy in 685 

Urticaria 555 

treatment of 556 

"Useful Drugs" 14, 50 

Uterine displacement in pregnancy 621 

hemorrhage in puerperal sepsis 634 

Vaccine therapy 712 

of anaphylaxis ., 705 

Vaccines, autogenous 713 

dating of 715 

....'.'. 714 



mixed 



stock 



714 



therapeutic use of 715 



Varicella 



106 



Venesection in pneumonia ' 170 

in uremia ' 334 

Vomiting in anesthesia gog 

of pregnancy '.'.'.'.'.'.'.'.'.'.'.'.'.'.' .427, 620 



to lessen irritation and. 



35 



Water by mouth ' 6 g3 

Waters 17 

Weaning of infants 652 

Weight, table of average height and, at different ages. ............ 29 

Weights and measures 20 

Wet nursing 653 

Whooping cough ' 82 



diet in 



85 



medical treatment of . . . 87 

prophylaxis of 82 

treatment of 84 

vaccine treatment of 86 

Wood alcohol poisoning [', ' 407 

Zinc chlorid as disinfectant '. 701 



Hi! 




1118 1 



Hill 



; ,ii 



